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Damery S, Jones J, Idris E, Cooper A, Minshall H, Clowes C, Jolly K. Mixed-methods evaluation of an enhanced asthma biologics clinical pathway in the West Midlands UK. NPJ Prim Care Respir Med 2024; 34:7. [PMID: 38693173 PMCID: PMC11063170 DOI: 10.1038/s41533-024-00365-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/10/2024] [Indexed: 05/03/2024] Open
Abstract
Biologic treatments can alleviate severe asthma symptoms and reduce health service use. However, service capacity limits and low referral rates from primary care indicate unmet patient need. We report a mixed-methods evaluation of an enhanced severe asthma pathway implemented in Staffordshire and Stoke-on-Trent, UK which aimed to optimise primary care referrals through training/education, and increased capacity in specialist clinics. Quantitative analysis assessed patient wait times between pathway stages, prescribing changes, exacerbations, hospital admissions and asthma control. Interviews with 12 stakeholders evaluated perceptions of the enhanced pathway across settings. In 12 months, 564 patients from 28 general practices were reviewed for biologics eligibility, of whom 125 (22.2%) were referred for specialist assessment. Wait times were significantly lower under the enhanced pathway when compared against historic patients following the standard pathway, and reduced overall from a mean of 76.4 to 26.7 weeks between referral and biologics initiation (p < 0.001). Patients commencing biologics (n = 46) showed significantly reduced reliever inhaler prescribing rates (p = 0.037), 60% lower oral steroid use (p < 0.001), significantly reduced exacerbation rates (p < 0.001) and fewer hospital admissions (p < 0.001) compared with the 12 months pre-treatment. Mean asthma control scores reduced from 3.13 pre-initiation to 1.89 post-initiation (p < 0.001) - a clinically significant improvement. Interviewees viewed the enhanced pathway positively, although ongoing issues related to difficulties engaging primary care amid concerns around increased workloads and pathway capacity. The large number of referrals generated from a comparatively small number of general practices confirms substantial unmet need that an enhanced severe asthma pathway could help address if implemented routinely.
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Affiliation(s)
- Sarah Damery
- Institute of Applied Health Research, University of Birmingham, Edgbaston, West Midlands, B15 2TT, UK.
| | - Janet Jones
- Institute of Applied Health Research, University of Birmingham, Edgbaston, West Midlands, B15 2TT, UK
| | - Elfatih Idris
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Newcastle Road, Staffordshire, ST4 6QG, UK
| | - Angela Cooper
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Newcastle Road, Staffordshire, ST4 6QG, UK
| | - Holly Minshall
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Newcastle Road, Staffordshire, ST4 6QG, UK
| | - Chris Clowes
- Health Innovation West Midlands, Faraday Wharf, Holt Street, Birmingham, B7 4BB, UK
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Edgbaston, West Midlands, B15 2TT, UK
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Ramlal M, van der Meer R, Bendien S. Treatable Traits in Pregnant Women with Asthma. Respiration 2024; 103:217-232. [PMID: 38471469 PMCID: PMC10997272 DOI: 10.1159/000536455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 12/19/2023] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Asthma is the most common chronic respiratory disease in pregnancy, affecting approximately 8-10% of pregnant women. Uncontrolled asthma is associated with adverse perinatal outcomes, including low birth weight, preterm birth, and maternal complications such as pre-eclampsia. SUMMARY A current approach to the management of chronic airway diseases is based on targeting treatable traits. The aim of this review was to define treatable traits in pregnant women with asthma based on recent literature and to determine personalized treatment options according to these traits. Traits addressed in this review that may improve asthma control and pregnancy outcomes are fractional exhaled nitric oxide-based asthma monitoring and treatment, medication adherence and inhalation technique, impaired lung function, smoking cessation and comorbidity including psychological conditions (depression and anxiety), obesity, rhinitis, gastroesophageal reflux disease, chronic rhinosinusitis with or without nasal polyps, and sleep apnea. KEY MESSAGES All the treatable traits discussed have the potential to improve asthma control and pregnancy outcomes in pregnant women with asthma. Further research is needed to determine which management approaches are best to improve asthma control during pregnancy, to identify other relevant treatable traits, and to determine whether the treatable trait approach is feasible and beneficial in pregnant women with asthma.
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Affiliation(s)
- Meera Ramlal
- Department of Biomedical Sciences, University of Amsterdam, Amsterdam, The Netherlands
| | - Renske van der Meer
- Department of Pulmonology, Haga Teaching Hospital, The Hague, The Netherlands
| | - Sarah Bendien
- Department of Pulmonology, Haga Teaching Hospital, The Hague, The Netherlands
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Gleeson PK, Morales KH, Buckey TM, Fadugba OO, Apter AJ, Christie JD, Himes BE. Factors associated with aeroallergen testing among adults with asthma in a large health system. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100167. [PMID: 37841071 PMCID: PMC10570953 DOI: 10.1016/j.jacig.2023.100167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/22/2023] [Accepted: 07/01/2023] [Indexed: 10/17/2023]
Abstract
Background Aeroallergen testing informs precision care for adults with asthma, yet the epidemiology of testing in this population remains poorly understood. Objective We sought to identify factors associated with receiving aeroallergen testing, the results of these tests, and subsequent reductions in exacerbation measures among adults with asthma. Methods We used electronic health record data to conduct a retrospective, observational cohort study of 30,775 adults with asthma who had an office visit with a primary care provider or an asthma specialist from January 1, 2017, to August 26, 2022. We used regression models to identify (1) factors associated with receiving any aeroallergen test and tests to 9 allergen categories after the index visit, (2) factors associated with positive test results, and (3) reductions in asthma exacerbation measures in the year after testing compared with before testing. Results Testing was received by 2201 patients (7.2%). According to multivariable models, receiving testing was associated with having any office visit with an allergy/immunology specialist during the study period (odds ratio [OR] = 91.3 vs primary care only [P < .001]) and having an asthma emergency department visit (OR = 1.62 [P = .004]) or hospitalization (OR = 1.62 [P = .03]) in the year before the index visit. Age 65 years or older conferred decreased odds of testing (OR = 0.74 vs age 18-34 years [P = .008]) and negative test results to 6 categories (P ≤ .04 for all comparisons). Black race conferred increased odds of testing (OR =1.22 vs White race [P = .01]) and positive test results to 8 categories (P < .04 for all comparisons). Exacerbation measures decreased after testing. Conclusion Aeroallergen testing was performed infrequently among adults with asthma and was associated with reductions in asthma exacerbation measures.
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Affiliation(s)
- Patrick K. Gleeson
- Section of Allergy and Immunology, Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Knashawn H. Morales
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Timothy M. Buckey
- Section of Allergy and Immunology, Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Olajumoke O. Fadugba
- Section of Allergy and Immunology, Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Andrea J. Apter
- Section of Allergy and Immunology, Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Jason D. Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Blanca E. Himes
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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4
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Montero Pérez O, Salazar González F, Sánchez Gómez E, Pérez Guerrero C. Pharmaceutical care and asthma: Protocol of an umbrella review of systematic reviews. FARMACIA HOSPITALARIA 2023; 47:T175-T179. [PMID: 37394378 DOI: 10.1016/j.farma.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 07/04/2023] Open
Abstract
INTRODUCTION Recent systematic reviews and meta-analyses suggest that pharmacists' interventions in asthma patients have a positive impact on health-related outcomes. Nevertheless, the association is not well established and the role of clinical pharmacists is poorly represented, as well as severe asthma patients. The aim of this overview of systematic reviews is to identify published systematic reviews assessing the impact of pharmacists' interventions on health-related outcomes measured in asthma patients, as well as to describe key components of the interventions, the outcomes assessed and any associations between pharmacists' interventions and health-related outcomes. METHODS PubMed, Embase, Scopus and the Cochrane Library will be searched from inception to December 2022. Systematic reviews of all study designs, severity of asthma and level of care that measured health-related outcomes will be considered. Methodological quality will be assessed using A Measurement Tool to Assess Systematic Reviews 2. Two independent investigators will perform the study selection, quality assessment and data collection, any discrepancy will be solved by a third investigator. Both narrative findings and meta-analysis of primary study data included in the systematic reviews will be synthesized. If data are appropriate for quantitative synthesis, the measures of association will be expressed as the risk ratio and difference in means. DISCUSSION The first results on the establishment of a multidisciplinary network for the management of asthmatic patients have shown the benefits of integrating different levels of care in disease control and morbidity reduction. Further studies showed benefits in hospital admissions, patients' basal oral corticosteroid dose, exacerbations and quality of life of asthma patients. A systematic review is the most appropriate design in order to summarize the literature and identify the evidence of the benefits of interventions performed by clinical pharmacists in asthma patients, especially those with severe uncontrolled asthma, and encourage future studies to stablish the role of clinical pharmacists in asthma units. REGISTRATION DETAILS Systematic review registration number: CRD42022372100.
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Affiliation(s)
- Olalla Montero Pérez
- Servicio de Farmacia, Institut Catalá d'Oncología, L'Hospitalet de Llobregat, España; Departamento de Farmacología, Facultad de Farmacia, Universidad de Sevilla, España.
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5
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Pérez OM, González FS, Gómez ES, Guerrero CP. Pharmaceutical care and asthma: Protocol of an umbrella review of systematic reviews. FARMACIA HOSPITALARIA 2023; 47:175-179. [PMID: 37173184 DOI: 10.1016/j.farma.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/16/2023] [Accepted: 03/17/2023] [Indexed: 05/15/2023] Open
Abstract
INTRODUCTION Recent systematic reviews and meta-analyses suggest that pharmacists' interventions in asthma patients have a positive impact on health-related outcomes. Nevertheless, the association is not well established and the role of clinical pharmacists is poorly represented, as well as severe asthma patients. The aim of this overview of systematic reviews is to identify published systematic reviews assessing the impact of pharmacists' interventions on health-related outcomes measured in asthma patients, as well as to describe key components of the interventions, the outcomes assessed and any associations between pharmacists' interventions and health-related outcomes. METHODS PubMed, Embase, Scopus and the Cochrane Library will be searched from inception to December 2022. Systematic reviews of all study designs, severity of asthma and level of care that measured health-related outcomes will be considered. Methodological quality will be assessed using A Measurement Tool to Assess Systematic Reviews 2. Two independent investigators will perform the study selection, quality assessment and data collection, any discrepancy will be solved by a third investigator. Both narrative findings and meta-analysis of primary study data included in the systematic reviews will be synthesised. If data are appropriate for quantitative synthesis, the measures of association will be expressed as the risk ratio and difference in means. DISCUSSION The first results on the establishment of a multidisciplinary network for the management of asthmatic patients have shown the benefits of integrating different levels of care in disease control and morbidity reduction. Further studies showed benefits in hospital admissions, patients' basal oral corticosteroid dose, exacerbations and quality of life of asthma patients. A systematic review is the most appropriate design in order to summarise the literature and identify the evidence of the benefits of interventions performed by clinical pharmacists in asthma patients, especially those with severe uncontrolled asthma, and encourage future studies to stablish the role of clinical pharmacists in asthma units. REGISTRATION DETAILS Systematic review registration number: CRD42022372100.
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Affiliation(s)
- Olalla Montero Pérez
- Servicio de Farmacia, Institut Catalá d'Oncología, L'Hospitalet de Llobregat, Spain; Departamento de Farmacología, Facultad de Farmacia, Universidad de Sevilla, Spain.
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Hussein N, Ramli R, Liew SM, Hanafi NS, Lee PY, Cheong AT, Sazlina SG, Mohd Ahad A, Patel J, Schwarze J, Pinnock H, Khoo EM. Healthcare resources, organisational support and practice in asthma in six public health clinics in Malaysia. NPJ Prim Care Respir Med 2023; 33:13. [PMID: 36973274 PMCID: PMC10042823 DOI: 10.1038/s41533-023-00337-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 03/07/2023] [Indexed: 03/29/2023] Open
Abstract
Asthma, a common chronic respiratory illness is mostly managed in primary care. We aimed to determine healthcare resources, organisational support, and doctors' practice in managing asthma in a Malaysian primary care setting. A total of six public health clinics participated. We found four clinics had dedicated asthma services. There was only one clinic which had a tracing defaulter system. Long-term controller medications were available in all clinics, but not adequately provided. Resources, educational materials, and equipment for asthma management were present, though restricted in number and not placed in main locations of the clinic. To diagnose asthma, most doctors used clinical judgement and peak flow metre measurements with reversibility test. Although spirometry is recommended to diagnose asthma, it was less practiced, being inaccessible and unskilled in using as the main reasons. Most doctors reported providing asthma self-management; asthma action plan, but for only half of the patients that they encountered. In conclusion, there is still room for improvement in the provision of clinic resources and support for asthma care. Utilising peak flow metre measurement and reversibility test suggest practical alternative in low resource for spirometry. Reinforcing education on asthma action plan is vital to ensure optimal asthma care.
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Affiliation(s)
- Norita Hussein
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia.
| | - Rizawati Ramli
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Su May Liew
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Nik Sherina Hanafi
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Ping Yein Lee
- UMeHealth Unit, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Ai Theng Cheong
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Shariff-Ghazali Sazlina
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | | | - Jaiyogesh Patel
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Jürgen Schwarze
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, Usher Institute, The University of Edinburgh, Edinburgh, UK
- Child Life and Health, Centre for Inflammation Research, The University of Edinburgh, Edinburgh, UK
| | - Hilary Pinnock
- NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
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Louis G, Pétré B, Schleich F, Zahrei HN, Donneau AF, Henket M, Paulus V, Guissard F, Guillaume M, Louis R. Predictors of change in asthma-related quality of life: a longitudinal real-life study in adult asthmatics. Qual Life Res 2023; 32:1507-1520. [PMID: 36595128 PMCID: PMC10123047 DOI: 10.1007/s11136-022-03339-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE Asthma negatively impacts health-related quality of life (HRQL). The objective is to investigate the longitudinal relationship between HRQL in asthma and disease control, demographic and clinical objective parameters in an adult population in real-life settings. METHODS We conducted a longitudinal study on adult asthmatics recruited from Liege University Hospital Asthma Clinic (Belgium) between 2011 and 2019. We selected those who had two visits and completed two patient-reported outcome measures (PROMs), the asthma control test (ACT) and the mini asthma quality of life questionnaire (AQLQ) (n = 290). AQLQ was the dependent variable. Demographic, functional and inflammatory characteristics, asthma control, and exacerbations were the independent variables. We applied generalized linear mixed models to identify the factors associated with change in AQLQ and its dimensions. RESULTS Median (IQR) time interval between the two visits was 7 (5-19) months. Overall, median (IQR) global AQLQ increased from 4.1 (3-5.1) to 4.6 (3.4-5.9) (p < 0.0001). All AQLQ dimensions significantly improved, apart the environmental one. AQLQ improved in patients who had both step-up and step-down pharmacological treatment as well as in patients reporting no change between the two visits. The fitted models indicated that change in ACT was the main predictor of change in AQLQ (p < 0.0001). A rise in 3 units in ACT predicted an improvement of 0.5 AQLQ (AUC-ROC = 0.85; p < 0.0001). Change in BMI inversely impacted global AQLQ (p < 0.01) and its activity dimension (p < 0.0001). CONCLUSION Asthma control and BMI are key predictors of asthma quality of life acting in an opposite direction. AQLQ may improve without step-up in the pharmacological treatment.
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Affiliation(s)
- Gilles Louis
- Department of Public Health, University of Liège, Liège, Belgium.
| | - Benoit Pétré
- Department of Public Health, University of Liège, Liège, Belgium
| | - Florence Schleich
- Department of Pneumology, University of Liège, GIGAI3, Liège, Belgium
| | | | | | - Monique Henket
- Department of Pneumology, University of Liège, GIGAI3, Liège, Belgium
| | - Virginie Paulus
- Department of Pneumology, University of Liège, GIGAI3, Liège, Belgium
| | | | | | - Renaud Louis
- Department of Pneumology, University of Liège, GIGAI3, Liège, Belgium
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Bleecker ER, Al-Ahmad M, Bjermer L, Caminati M, Canonica GW, Kaplan A, Papadopoulos NG, Roche N, Ryan D, Tohda Y, Yáñez A, Price D. Systemic corticosteroids in asthma: A call to action from World Allergy Organization and Respiratory Effectiveness Group. World Allergy Organ J 2022; 15:100726. [PMID: 36582404 PMCID: PMC9761384 DOI: 10.1016/j.waojou.2022.100726] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/11/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022] Open
Abstract
Systemic corticosteroids (SCS) are a highly effective treatment for acute exacerbations and long-term symptom control in asthma. Long-term SCS use is highly prevalent across all asthma severities, occurring in over 20% of patients with severe or uncontrolled disease globally. It is now well known that exposure to both long-term and repeated acute courses of SCS is associated with a high risk of serious adverse effects (AEs), such as osteoporosis, and metabolic and cardiovascular complications, especially when prescribed onto a background of other corticosteroids. The aim of this call-to-action article, endorsed by the World Allergy Organization and the Respiratory Effectiveness Group, is to review the accumulating evidence on the burden of SCS on patients with asthma and provide an overview of potential strategies for implementing SCS Stewardship. Primary prevention of exacerbations and improvement of asthma control is a key first step in achieving SCS Stewardship, by optimizing maintenance asthma medications and addressing modifiable risk factors, such as adherence and inhaler technique. Other key elements of SCS Stewardship include increasing appropriate specialist referrals for multidisciplinary review, assessment of biomarkers, and consideration of oral corticosteroid-sparing add-on therapies (eg, biologics). In cases where SCS use is deemed clinically justified, it should be tapered to the lowest possible dose. In addition, patients receiving long-term SCS or frequent acute courses should be closely monitored for emergence of SCS-related AEs. Because of the extensive data available on the costly and burdensome AEs associated with SCS use, as well as the range of treatment options now available, there is a need for healthcare providers (HCPs) to carefully evaluate whether the benefits of SCS outweigh the potential harms, to adopt SCS-sparing and Stewardship strategies, and to consider alternative therapies where possible. Development of a structured and collaborative SCS Stewardship approach is urgently required to protect patients from the potential harm of SCS use.
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Affiliation(s)
- Eugene R. Bleecker
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Mona Al-Ahmad
- Microbiology Department, College of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, University Hospital, Lund, Sweden
| | - Marco Caminati
- Department of Medicine, University of Verona, Verona, Italy
| | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Alan Kaplan
- Family Physician Airways Group of Canada, Stouffville, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Nikolaos G. Papadopoulos
- Division of Infection, Immunity & Respiratory Medicine, Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
- Allergy Department, 2nd Pediatric Clinic, Athens General Children's Hospital ‘P&A Kyriakou’, University of Athens, Athens, Greece
| | - Nicolas Roche
- Department of Respiratory Medicine, APHP. Centre Université Paris Cité, Cochin Hospital (AP-HP) and Institute (UMR1016), Paris, France
| | - Dermot Ryan
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Yuji Tohda
- Kindai University Hospital, Osaka, Japan
| | - Anahí Yáñez
- Center for Research on Allergies and Respiratory Diseases (InAER), Buenos Aires, Argentina
| | - David Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Corresponding author. Professor David B Price, Observational and Pragmatic Research Institute, 22 Sin Ming Lane, #06 Midview City, Singapore 573969
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Redmond C, Heaney LG, Chaudhuri R, Jackson DJ, Menzies-Gow A, Pfeffer P, Busby J. Benefits of specialist severe asthma management: demographic and geographic disparities. Eur Respir J 2022; 60:2200660. [PMID: 35777771 PMCID: PMC9753476 DOI: 10.1183/13993003.00660-2022] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/23/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The benefits of specialist assessment and management have yet to be evaluated within the biologic era of UK severe asthma treatment, and potential disparities have not been considered. METHODS In an uncontrolled before-and-after study, we compared asthma symptoms (Asthma Control Questionnaire-6 (ACQ-6)), exacerbations, unscheduled secondary care use, lung function (forced expiratory volume in 1 s (FEV1)) and oral corticosteroid (OCS) dose after 1 year. We compared outcomes by sex, age (18-34, 35-49, 50-64 and ≥65 years), ethnicity (Caucasian versus non-Caucasian) and hospital site after adjusting for demographics and variation in biologic therapy use. RESULTS 1140 patients were followed-up for 1370 person-years from 12 specialist centres. At annual review, ACQ-6 score was reduced by a median (interquartile range (IQR)) of 0.7 (0.0-1.5), exacerbations by 75% (33-100%) and unscheduled secondary care by 100% (67-100%). FEV1 increased by a median (IQR) of 20 (-200-340) mL, while OCS dose decreased for 67% of patients. Clinically meaningful improvements occurred across almost all patients, including those not receiving biologic therapy. There was little evidence of differences across demographic groups, although those aged ≥65 years demonstrated larger reductions in exacerbations (69% versus 52%; p<0.001) and unscheduled care use (77% versus 50%; p<0.001) compared with patients aged 18-34 years. There were >2-fold differences between the best and worst performing centres across all study outcomes. CONCLUSIONS Specialist assessment and management is associated with substantially improved patient outcomes, which are broadly consistent across demographic groups and are not restricted to those receiving biologic therapy. Significant variation exists between hospitals, which requires further investigation.
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Affiliation(s)
- Charlene Redmond
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
| | - Liam G Heaney
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
- Belfast Health and Social Care NHS Trust, Belfast, UK
| | | | - David J Jackson
- Guy's Severe Asthma Centre, Guy's and St Thomas' Hospitals, London, UK
- School of Immunology and Microbial Sciences, King's College London, London, UK
| | | | | | - John Busby
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University, Belfast, UK
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10
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Okelo SO. Racial Inequities in Asthma Care. Semin Respir Crit Care Med 2022; 43:684-708. [DOI: 10.1055/s-0042-1756492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractRacial inequities in asthma care are evolving as a recognized factor in long-standing inequities in asthma outcomes (e.g., hospitalization and mortality). Little research has been conducted regarding the presence or absence of racial inequities among patients seen in asthma specialist settings, this is an important area of future research given that asthma specialist care is recommended for patients experiencing the poor asthma outcomes disproportionately experienced by Black and Hispanic patients. This study provides a systematic review of racial asthma care inequities in asthma epidemiology, clinical assessment, medication prescription, and asthma specialist referral practices.
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Affiliation(s)
- Sande O. Okelo
- Division of Pediatric Pulmonology and Sleep Medicine, The David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California
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11
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Varkonyi-Sepp J, Freeman A, Ainsworth B, Kadalayil LP, Haitchi HM, Kurukulaaratchy RJ. Multimorbidity in Difficult Asthma: The Need for Personalised and Non-Pharmacological Approaches to Address a Difficult Breathing Syndrome. J Pers Med 2022; 12:jpm12091435. [PMID: 36143220 PMCID: PMC9500722 DOI: 10.3390/jpm12091435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/21/2022] Open
Abstract
Three to ten percent of people living with asthma have difficult-to-treat asthma that remains poorly controlled despite maximum levels of guideline-based pharmacotherapy. This may result from a combination of multiple adverse health issues including aggravating comorbidities, inadequate treatment, suboptimal inhaler technique and/or poor adherence that may individually or collectively contribute to poor asthma control. Many of these are potentially "treatable traits" that can be pulmonary, extrapulmonary, behavioural or environmental factors. Whilst evidence-based guidelines lead clinicians in pharmacological treatment of pulmonary and many extrapulmonary traits, multiple comorbidities increase the burden of polypharmacy for the patient with asthma. Many of the treatable traits can be addressed with non-pharmacological approaches. In the current healthcare model, these are delivered by separate and often disjointed specialist services. This leaves the patients feeling lost in a fragmented healthcare system where clinical outcomes remain suboptimal even with the best current practice applied in each discipline. Our review aims to address this challenge calling for a paradigm change to conceptualise difficult-to-treat asthma as a multimorbid condition of a "Difficult Breathing Syndrome" that consequently needs a holistic personalised care attitude by combining pharmacotherapy with the non-pharmacological approaches. Therefore, we propose a roadmap for an evidence-based multi-disciplinary stepped care model to deliver this.
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Affiliation(s)
- Judit Varkonyi-Sepp
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Clinical Health Psychology Department, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Anna Freeman
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Ben Ainsworth
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Department of Psychology, University of Bath, Bath BA2 7AY, UK
| | - Latha Perunthadambil Kadalayil
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Hans Michael Haitchi
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Institute for Life Sciences, University of Southampton, Southampton SO16 6YD, UK
| | - Ramesh J Kurukulaaratchy
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Respiratory Medicine Department, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Isle of Wight, Newport PO30 5TG, UK
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Abstract
Severe asthma is a heterogeneous syndrome with several clinical variants and often represents a complex disease requiring a specialized and multidisciplinary approach, as well as the use of multiple drugs. The prevalence of severe asthma varies from one country to another, and it is estimated that 50% of these patients present a poor control of their disease. For the best management of the patient, it is necessary a correct diagnosis, an adequate follow-up and undoubtedly to offer the best available treatment, including biologic treatments with monoclonal antibodies. With this objective, this consensus process was born, which began in its first version in 2018, whose goal is to offer the patient the best possible management of their disease in order to minimize their symptomatology. For this 2020 consensus update, a literature review was conducted by the authors. Subsequently, through a two-round interactive Delphi process, a broad panel of asthma experts from SEPAR and the regional pulmonology societies proposed the recommendations and conclusions contained in this document.
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McDonald VM, Gibson PG. Multidisciplinary care in chronic airway diseases: the Newcastle model. ERJ Open Res 2022; 8:00215-2022. [PMID: 35983538 PMCID: PMC9379354 DOI: 10.1183/23120541.00215-2022] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/10/2022] [Indexed: 11/05/2022] Open
Abstract
Chronic airway diseases including, asthma and chronic obstructive pulmonary disease (COPD) are prevalent and high burden conditions with the majority of patients successfully managed in the primary care setting. However, some patients with more complex disease such as difficult-to-treat or severe asthma, or complex COPD, tertiary care is required. This review provides an overview of the successful tertiary care multidisciplinary respiratory service that operates in Newcastle, New South Wales, Australia, which has been integrated into the tertiary care outpatient clinics for almost three decades. The service is multifaceted in terms of the clinical care it provides, and includes an “Inpatient service”, “Asthma Management Service”, “Difficult Airway Clinic”, “Drug Administration Clinic”, “Rapid Access Clinic”, “Pulmonary Rehabilitation” and has an integrated research programme. The core of the multidisciplinary approach to airway diseases is a person-centred model of care, the “Treatable Traits” approach. The staffing of this service comprises of consultant physicians, respiratory advanced trainees, respiratory scientists, physiotherapists, speech pathologists, nurse specialists and a nurse consultant. Patients that present to this service undergo an initial assessment and clinical review by team members, synthesis of relevant data, and development of a diagnosis and management plan. Based on this review specific interventions are determined according to the traits identified. Overtime the service has evolved to accommodate the increasing numbers of patients requiring access to the “Difficult Airways Clinic” assessment and therapies. This has been facilitated by partnered with the Centres of Excellence in Severe Asthma and Treatable Traits to develop educational and practice management tools.
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Skov IR, Madsen H, Andersen JH, Pottegård A, Davidsen JR. Trends and predictors of specialist assessments in oral corticosteroid treated asthma among young adults. ERJ Open Res 2022; 8:00142-2022. [PMID: 35898811 PMCID: PMC9309342 DOI: 10.1183/23120541.00142-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/25/2022] [Indexed: 11/05/2022] Open
Abstract
BackgroundRepeated oral corticosteroid use indicates uncontrolled disease among asthma patients and referral for asthma specialist assessment is recommended. We aimed to describe trends and predictors associated with specialist contacts among young adults with asthma and repeated oral corticosteroid use.MethodsIndividuals aged 18–45 years with ≥2 dispensed asthma medication prescriptions and two dispended oral corticosteroid prescriptions (including short-term and long-term treatments) within 12 months during 1999–2018 were identified by use of Danish healthcare registers. The frequency of specialist contacts within 1 year of follow-up was assessed among individuals without previous specialist contacts within 5 years of inclusion. Factors associated with specialist contact were identified by logistic regression models. Furthermore, oral corticosteroid prescriber sources were assessed.ResultsFor the 11 223 individuals included, 2444 (22%) had previous specialist contacts care within 5 years prior of inclusion and additionally 926 (8.3%) within 1 year of follow-up. Among those without previous specialist contacts (n 8779), the frequency of incident specialist contacts within 1 year of follow-up increased from 6.3% in 1999 to 18% in 2017. Factors associated with incident specialist contacts included dispensing ≥12 SABA canisters and previous asthma-related emergency department visits and hospitalisations. The majority of oral corticosteroid prescriptions at baseline (71%) were prescribed by general practitioners, though with decreasing proportions from 1999–2018.ConclusionsThe majority (70%) of young adults with asthma and repeated oral corticosteroid use do not seem to receive specialist assessment in Denmark. This highlights a potential room for improvement in the patient referral pathway for at-risk asthma patients.
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Sarwar MR, McDonald VM, Abramson MJ, McLoughlin RF, Geethadevi GM, George J. Effectiveness of Interventions Targeting Treatable Traits for the Management of Obstructive Airway Diseases: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2333-2345.e21. [PMID: 35643276 DOI: 10.1016/j.jaip.2022.05.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 03/30/2022] [Accepted: 05/02/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND The management of obstructive airway diseases (OADs) is complex. The treatable traits (TTs) approach may be an effective strategy for managing OADs. OBJECTIVE To determine the effectiveness of interventions targeting TTs for managing OADs. METHODS Ovid Embase, Medline, CENTRAL, and CINAHL Plus were searched from inception to March 9, 2022. Studies of interventions targeting at least 1 TT from pulmonary, extrapulmonary, and behavioral/lifestyle domains were included. Two reviewers independently extracted relevant data and performed risk-of-bias assessments. Meta-analyses were performed using random-effects models. Subgroup and sensitivity analyses were carried out to explore heterogeneity and to determine the effects of outlying studies. RESULTS Eleven studies that used the TTs approach for OAD management were identified. Traits targeted within each study ranged from 13 to 36. Seven controlled trials were included in meta-analyses. TT interventions were effective at improving health-related quality of life (mean difference [MD] = -6.96, 95% CI: -9.92 to -4.01), hospitalizations (odds ratio [OR] = 0.52, 95% CI: 0.39 to 0.69), all-cause-1-year mortality (OR = 0.65, 95% CI: 0.45 to 0.95), dyspnea score (MD = -0.29, 95% CI: -0.46 to -0.12), anxiety (MD = -1.61, 95% CI: -2.92 to -0.30), and depression (MD = -2.00, 95% CI: -3.53 to -0.47). CONCLUSION Characterizing TTs and targeted interventions can improve outcomes in OADs, which offer a promising model of care for OADs.
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Affiliation(s)
- Muhammad Rehan Sarwar
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Vanessa Marie McDonald
- National Health and Medical Research Council, Centre for Research Excellence in Severe Asthma and Centre of Excellence in Treatable Traits, the University of Newcastle, Newcastle, Australia; The Priority Research Centre for Healthy Lungs, School of Nursing and Midwifery, Newcastle, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, Australia
| | - Michael John Abramson
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Rebecca Frances McLoughlin
- National Health and Medical Research Council, Centre for Research Excellence in Severe Asthma and Centre of Excellence in Treatable Traits, the University of Newcastle, Newcastle, Australia; The Priority Research Centre for Healthy Lungs, School of Nursing and Midwifery, Newcastle, Australia
| | | | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.
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16
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Abstract
ABSTRACT Severe asthma is "asthma which requires treatment with high dose inhaled corticosteroids (ICS) plus a second controller (and/or systemic corticosteroids) to prevent it from becoming 'uncontrolled' or which remains 'uncontrolled' despite this therapy." The state of control was defined by symptoms, exacerbations and the degree of airflow obstruction. Therefore, for the diagnosis of severe asthma, it is important to have evidence for a diagnosis of asthma with an assessment of its severity, followed by a review of comorbidities, risk factors, triggers and an assessment of whether treatment is commensurate with severity, whether the prescribed treatments have been adhered to and whether inhaled therapy has been properly administered. Phenotyping of severe asthma has been introduced with the definition of a severe eosinophilic asthma phenotype characterized by recurrent exacerbations despite being on high dose ICS and sometimes oral corticosteroids, with a high blood eosinophil count and a raised level of nitric oxide in exhaled breath. This phenotype has been associated with a Type-2 (T2) inflammatory profile with expression of interleukin (IL)-4, IL-5, and IL-13. Molecular phenotyping has also revealed non-T2 inflammatory phenotypes such as Type-1 or Type-17 driven phenotypes. Antibody treatments targeted at the T2 targets such as anti-IL5, anti-IL5Rα, and anti-IL4Rα antibodies are now available for treating severe eosinophilic asthma, in addition to anti-immunoglobulin E antibody for severe allergic asthma. No targeted treatments are currently available for non-T2 inflammatory phenotypes. Long-term azithromycin and bronchial thermoplasty may be considered. The future lies with molecular phenotyping of the airway inflammatory process to refine asthma endotypes for precision medicine.
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17
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Eger K, Paroczai D, Bacon A, Schleich F, Sergejeva S, Bourdin A, Vachier I, Zervas E, Katsoulis K, Papapetrou D, Kostikas K, Csoma Z, Heffler E, Canonica GW, Grisle I, Bieksiene K, Palacionyte J, Ten Brinke A, Hashimoto S, Smeenk FWJM, Braunstahl GJ, van der Sar S, Mihălţan F, Nenasheva N, Peredelskaya M, Zvezdin B, Čekerevac I, Hromiš S, Ćupurdija V, Lazic Z, Milenkovic B, Dimic-Janjic S, Yasinska V, Dahlén B, Bossios A, Lazarinis N, Aronsson D, Egesten A, Munir AKM, Ahlbeck L, Janson C, Škrgat S, Edelbaher N, Leuppi J, Jaun F, Rüdiger J, Pavlov N, Gianella P, Fischer R, Charbonnier F, Chaudhuri R, Smith SJ, Doe S, Fawdon M, Masoli M, Heaney L, Haitchi HM, Kurukulaaratchy R, Fulton O, Frankemölle B, Gibson T, Needham K, Howarth P, Djukanovic R, Bel E, Hyland M. The effect of the COVID-19 pandemic on severe asthma care in Europe: will care change for good? ERJ Open Res 2022; 8:00065-2022. [PMID: 35582679 PMCID: PMC8994963 DOI: 10.1183/23120541.00065-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic has put pressure on healthcare services, forcing the reorganisation of traditional care pathways. We investigated how physicians taking care of severe asthma patients in Europe reorganised care, and how these changes affected patient satisfaction, asthma control and future care. Methods In this European-wide cross-sectional study, patient surveys were sent to patients with a physician-diagnosis of severe asthma, and physician surveys to severe asthma specialists between November 2020 and May 2021. Results 1101 patients and 268 physicians from 16 European countries contributed to the study. Common physician-reported changes in severe asthma care included use of video/phone consultations (46%), reduced availability of physicians (43%) and change to home-administered biologics (38%). Change to phone/video consultations was reported in 45% of patients, of whom 79% were satisfied or very satisfied with this change. Of 709 patients on biologics, 24% experienced changes in biologic care, of whom 92% were changed to home-administered biologics and of these 62% were satisfied or very satisfied with this change. Only 2% reported worsening asthma symptoms associated with changes in biologic care. Many physicians expect continued implementation of video/phone consultations (41%) and home administration of biologics (52%). Conclusions Change to video/phone consultations and home administration of biologics was common in severe asthma care during the COVID-19 pandemic and was associated with high satisfaction levels in most but not all cases. Many physicians expect these changes to continue in future severe asthma care, though satisfaction levels may change after the pandemic.
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Affiliation(s)
- Katrien Eger
- Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
- Co-first authors
| | - Dora Paroczai
- Csongrad County Hospital and Dept of Pulmonology, University of Szeged, Szeged, Hungary
- Co-first authors
| | - Alison Bacon
- School of Psychology, University of Plymouth, Plymouth, UK
| | | | | | - Arnaud Bourdin
- PhyMedExp, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Isabelle Vachier
- PhyMedExp, CHU Montpellier, University of Montpellier, Montpellier, France
| | | | | | | | | | - Zsuzsanna Csoma
- National Koranyi Institute for Pulmonology, Budapest, Hungary
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy - IRCCS Humanitas Research Hospital - Rozzano (MI), Italy
- Departmento of Biomedical Sciences - Humanitas University - Pieve Emanuele (MI), Italy
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy - IRCCS Humanitas Research Hospital - Rozzano (MI), Italy
- Departmento of Biomedical Sciences - Humanitas University - Pieve Emanuele (MI), Italy
| | | | | | | | | | - Simone Hashimoto
- Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | | | | | - Natalia Nenasheva
- Russian Medical Academy of Continuous Professional Education of the Ministry of Healthcare of the Russian Federation, Moscow, Russian Federation
| | - Marina Peredelskaya
- Russian Medical Academy of Continuous Professional Education of the Ministry of Healthcare of the Russian Federation, Moscow, Russian Federation
| | - Biljana Zvezdin
- Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia
- Medical Faculty Novi Sad, University of Novi Sad, Bucharest, Romania
| | - Ivan Čekerevac
- Clinic for Pulmonology, University Clinical Center Kragujevac, Kragujevac, Serbia
- Dept of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Sanja Hromiš
- Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia
| | - Vojislav Ćupurdija
- Clinic for Pulmonology, University Clinical Center Kragujevac, Kragujevac, Serbia
- Dept of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Zorica Lazic
- Clinic for Pulmonology, University Clinical Center Kragujevac, Kragujevac, Serbia
- Dept of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Branislava Milenkovic
- Clinic for Pulmonology, University Clinical Center of Serbia, Belgrade Medical faculty, Belgrade, Serbia
| | - Sanja Dimic-Janjic
- Clinic for Pulmonology, University Clinical Center of Serbia, Belgrade Medical faculty, Belgrade, Serbia
| | - Valentyna Yasinska
- Karolinska Severe Asthma Center, Dept of Respiratory Medicine and Allergy, Karolinska University Hospital, Huddinge and Dept of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Barbro Dahlén
- Karolinska Severe Asthma Center, Dept of Respiratory Medicine and Allergy, Karolinska University Hospital, Huddinge and Dept of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Apostolos Bossios
- Karolinska Severe Asthma Center, Dept of Respiratory Medicine and Allergy, Karolinska University Hospital, Huddinge and Dept of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Nikolaos Lazarinis
- Karolinska Severe Asthma Center, Dept of Respiratory Medicine and Allergy, Karolinska University Hospital, Huddinge and Dept of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - David Aronsson
- Respiratory Medicine and Allergology, Dept of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - Arne Egesten
- Respiratory Medicine and Allergology, Dept of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | - Abul Kashem Mohammad Munir
- Respiratory Medicine and Allergology, Dept of Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden
| | | | - Christer Janson
- Dept of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Sabina Škrgat
- Dept for Pulmonary Diseases, University Medical Centre Ljubljana, Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | | | - Joerg Leuppi
- Medical Faculty University of Basel and Cantonal Hospital Baselland, Liestal, Switzerland
| | - Fabienne Jaun
- Medical Faculty University of Basel and Cantonal Hospital Baselland, Liestal, Switzerland
| | | | - Nikolay Pavlov
- Dept of Pulmonary Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | | | | | | | - Simon Doe
- Royal Victoria Infirmary, Newcastle, UK
| | | | | | - Liam Heaney
- Wellcome-Wolfson Centre for Experimental Medicine, Queens University Belfast, Belfast, UK
| | | | | | | | | | | | | | - Peter Howarth
- Global Medical Affairs, Specialty Medicine TA, GSK, Brentford, UK
| | | | - Elisabeth Bel
- Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Menzies-Gow A, Moore WC, Wechsler ME. Difficult-to-Control Asthma Management in Adults. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:378-384. [PMID: 34954122 DOI: 10.1016/j.jaip.2021.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/15/2021] [Indexed: 02/08/2023]
Abstract
The management of difficult-to-control asthma remains a significant challenge, which frequently requires the input of the wider multidisciplinary team. This review covers the importance of systematic assessment, phenotyping, treatment options at step 4, an overview of biologics and novel therapies for type 2 (T2) inflammation, and nonpharmacological interventions. Once people have been identified as suffering from difficult-to-control asthma, it is important to use the systematic assessment process to allow accurate diagnosis and optimization of adherence as well as identification and treatment of any relevant comorbidities. Before initiating a biologic, it is important to optimize inhaled therapies and sufficiently phenotype individual patients to allow for the logical use of biologic agents targeting T2 inflammation. For patients who either do not have evidence of T2 inflammation or remain symptomatic despite biologics, attention should be paid to the available nonpharmacological interventions. Difficult-to-treat asthma remains an area of significant unmet need, but improvements in models of service delivery and the ongoing pharmacological pipeline are causes for significant optimism that sooner rather than later there will no longer be asthmatic patients who are difficult to treat.
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Affiliation(s)
- Andrew Menzies-Gow
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, UK.
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19
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Kim SH, Lee H, Park SY, Park SY, Song WJ, Kim JH, Park HW, Cho YS, Yoon HJ. The Korean Severe Asthma Registry (KoSAR): real world research in severe asthma. Korean J Intern Med 2022; 37:249-260. [PMID: 35184515 PMCID: PMC8925953 DOI: 10.3904/kjim.2021.403] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/17/2021] [Indexed: 11/27/2022] Open
Abstract
Severe asthma constitutes a serious health burden with significant morbidity and socioeconomic costs. The development and introduction of new biologics targeting type 2 inflammation changed the paradigm for management of severe asthma and initiated a biological era. These changes impose a challenge to clinicians in managing difficult-to-treat and severe asthma. To understand the characteristics and heterogeneity of severe asthma and to develop a better strategy to manage it, the Korean Academy of Asthma, Allergy and Clinical Immunology, Working Group on Severe Asthma, has organized the Korean Severe Asthma Registry (KoSAR). In this review, we describe the challenges of severe asthma management regarding diagnosis, disease burden, heterogeneity, guidelines, and organization of severe asthma clinics. This review also examines the current global activities of national and regional registries and study groups. In addition, we present the KoSAR vision and organization and describe the findings of KoSAR in comparison with those of other countries.
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Affiliation(s)
- Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul,
Korea
| | - Hyun Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul,
Korea
| | - So-Young Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul,
Korea
| | - So Young Park
- Department of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul,
Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Joo-Hee Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang,
Korea
| | - Heung-Woo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - You Sook Cho
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul,
Korea
| | - Ho Joo Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul,
Korea
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Ghaleb Dailah H. Investigating the Outcomes of an Asthma Educational Program and Useful Influence in Public Policy. Front Public Health 2021; 9:736203. [PMID: 34900893 PMCID: PMC8661094 DOI: 10.3389/fpubh.2021.736203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Abstract
The study was conducted to evaluate the effectiveness of an asthma educational program for asthma control, asthma self-management, asthma knowledge, and patient activation. The study analyzes different demographic variables with the purpose of investigating which asthma patients performed better than others. Based on these demographic characteristics, the study provides several recommendations for various stakeholders. The study is based on a positivist approach since its purpose is to investigate the consequences of an asthma educational program with a view to generalizing the results to a larger population. The study targets public and private hospitals which have applied the asthma educational program in collaboration with the Saudi Initiative for Asthma (SINA). Multiple questionnaires were deployed 263 valid responses were received from patients of public and private hospitals using online and offline data collection method. Several parametric and non-parametric tests were carried out in terms of data analysis. The results reveal that patients in the intervention group obtained high scores and were therefore more knowledgeable and able to control their asthma compared to the control group. Overall, patients in the intervention group performed better in terms of asthma control, asthma self-management and knowledge and awareness. There was a high level of patient activation in this group. In the context of demographic features, it was found that patients who are married and are undergraduate degree holders in employment scored high compared to patients who were young, single, post-graduate degree holders that were mainly self-employed. The results of this study can guide policy makers, SINA authorities, and hospitals as to which demographic category of asthma patients require immediate attention. The significance of asthma educational programmes has increased especially through social media platforms as the number of adult patients continues to increase day by day.
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Czira A, Turner M, Martin A, Hinds D, Birch H, Gardiner F, Zhang S. A systematic literature review of burden of illness in adults with uncontrolled moderate/severe asthma. Respir Med 2021; 191:106670. [PMID: 34883444 DOI: 10.1016/j.rmed.2021.106670] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 10/14/2021] [Accepted: 10/23/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND There are limited published data on the burden of moderate/severe uncontrolled asthma. METHODS We conducted a systematic literature review to better understand the impact of moderate-to-severe asthma in the US, the UK, Germany, France, Italy, Spain, Canada, Japan, and Australia in terms of prevalence, clinical measures, health-related quality of life (HRQoL) and economic burden, for patients whose asthma is uncontrolled despite inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) therapy. RESULTS The prevalence of uncontrolled asthma among patients with moderate/severe disease varied but was as high as 100% in some subgroups. Patients with uncontrolled asthma generally had poor lung function (mean/median pre-bronchodilator forced expiratory volume in 1 second [FEV1]: 1.69-2.45 L; mean/median pre-bronchodilator percent predicted FEV1: 57.2-79.7). There was also a substantial but variable exacerbation burden associated with uncontrolled asthma, with the annualised rate of exacerbations ranging from 1.30 to 7.30 when considering various patient subgroups. Furthermore, the annualised rate of severe exacerbations ranged from 1.66 to 3.60. The HRQoL burden measured using disease-specific and generic instruments consistently demonstrated substantial impairment of HRQoL for those with uncontrolled asthma; Asthma Quality of Life Questionnaire scores ranged from 3.00 to 5.20, whilst EurQol-5 Dimensions index scores ranged from 0.53 to 0.59. Direct, indirect and total costs together with consumption of other healthcare resources associated with managing uncontrolled asthma were also substantial in the population studied; no caregiver burden was identified. CONCLUSIONS Our findings suggest that significant unmet needs exist for patients with uncontrolled asthma despite the availability of ICS/LABA therapy. Novel treatments are needed to help reduce the burden to patients, healthcare systems and society.
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Affiliation(s)
| | - Monica Turner
- Evidera, Evidence Synthesis, Modeling & Communication, Waltham, MA, United States.
| | - Amber Martin
- Evidera, Evidence Synthesis, Modeling & Communication, Waltham, MA, United States.
| | - David Hinds
- GSK, R&D Global Medical, Collegeville, PA, United States.
| | - Helen Birch
- GSK, R&D Global Medical, Brentford, Middlesex, UK.
| | | | - Shiyuan Zhang
- GSK, R&D Global Medical, Collegeville, PA, United States.
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22
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Watchorn D, Menzies-Gow A. Oral corticosteroid stewardship for asthma: Time to move from theory to routine clinical practice. Respirology 2021; 26:1094-1095. [PMID: 34668272 DOI: 10.1111/resp.14171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/07/2021] [Indexed: 11/29/2022]
Affiliation(s)
- David Watchorn
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Andrew Menzies-Gow
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
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23
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Blakey J, Chung LP, McDonald VM, Ruane L, Gornall J, Barton C, Bosnic-Anticevich S, Harrington J, Hew M, Holland AE, Hopkins T, Jayaram L, Reddel H, Upham JW, Gibson PG, Bardin P. Oral corticosteroids stewardship for asthma in adults and adolescents: A position paper from the Thoracic Society of Australia and New Zealand. Respirology 2021; 26:1112-1130. [PMID: 34587348 PMCID: PMC9291960 DOI: 10.1111/resp.14147] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 08/04/2021] [Accepted: 08/31/2021] [Indexed: 12/13/2022]
Abstract
Oral corticosteroids (OCS) are frequently used for asthma treatment. This medication is highly effective for both acute and chronic diseases, but evidence indicates that indiscriminate OCS use is common, posing a risk of serious side effects and irreversible harm. There is now an urgent need to introduce OCS stewardship approaches, akin to successful initiatives that optimized appropriate antibiotic usage. The aim of this TSANZ (Thoracic Society of Australia and New Zealand) position paper is to review current knowledge pertaining to OCS use in asthma and then delineate principles of OCS stewardship. Recent evidence indicates overuse and over-reliance on OCS for asthma and that doses >1000 mg prednisolone-equivalent cumulatively are likely to have serious side effects and adverse outcomes. Patient perspectives emphasize the detrimental impacts of OCS-related side effects such as weight gain, insomnia, mood disturbances and skin changes. Improvements in asthma control and prevention of exacerbations can be achieved by improved inhaler technique, adherence to therapy, asthma education, smoking cessation, multidisciplinary review, optimized medications and other strategies. Recently, add-on therapies including novel biological agents and macrolide antibiotics have demonstrated reductions in OCS requirements. Harm reduction may also be achieved through identification and mitigation of predictable adverse effects. OCS stewardship should entail greater awareness of appropriate indications for OCS prescription, risk-benefits of OCS medications, side effects, effective add-on therapies and multidisciplinary review. If implemented, OCS stewardship can ensure that clinicians and patients with asthma are aware that OCS should not be used lightly, while providing reassurance that asthma can be controlled in most people without frequent use of OCS.
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Affiliation(s)
- John Blakey
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Medical School, Curtin University, Perth, Western Australia, Australia
| | - Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, College of Health Medicine and Wellbeing, The University of Newcastle, New Lambton Heights, New South Wales, Australia
| | - Laurence Ruane
- Monash Lung and Sleep, Monash University and Medical Centre, Melbourne, Victoria, Australia
| | - John Gornall
- Centre of Excellence in Severe Asthma, The University of Newcastle, New Lambton Heights, New South Wales, Australia
| | - Chris Barton
- Department of General Practice, Monash University, Melbourne, Victoria, Australia
| | - Sinthia Bosnic-Anticevich
- Sydney Pharmacy School, The University of Sydney AND Quality Use of Respiratory Medicines Group, The Woolcock Institute of Medical Research, Sydney, New South Wales, Australia
| | - John Harrington
- John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, Victoria, Australia
| | - Anne E Holland
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Trudy Hopkins
- South Eastern Sydney Health Department, Sydney, New South Wales, Australia
| | - Lata Jayaram
- Department of Respiratory Medicine, Western Health and University of Melbourne, Melbourne, Victoria, Australia
| | - Helen Reddel
- The Woolcock Institute of Medical Research and The University of Sydney, Sydney, New South Wales, Australia
| | - John W Upham
- The University of Queensland, Diamantina Institute AND Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, College of Health Medicine and Wellbeing, The University of Newcastle, New Lambton Heights, New South Wales, Australia.,John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Philip Bardin
- Monash Lung Sleep Allergy & Immunology, Monash University and Medical Centre, Melbourne, Victoria, Australia
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24
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Felix SN, Agondi RC, Aun MV, Olivo CR, de Almeida FM, Amorim TS, Cezario JC, Giavina-Bianchi P, Tiberio IDFLC, de Martins MDA, Romanholo BMS. Clinical, functional and inflammatory evaluation in asthmatic patients after a simple short-term educational program: a randomized trial. Sci Rep 2021; 11:18267. [PMID: 34521963 PMCID: PMC8440547 DOI: 10.1038/s41598-021-97846-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/10/2021] [Indexed: 02/08/2023] Open
Abstract
This study aimed to evaluate the clinical evolution, functional parameters and inflammatory activity of asthma in patients who submitted to an educational intervention. 58 adult patients over 18 years of age with partly controlled and uncontrolled asthma were randomized into an intervention group (IG) (N = 32) and a control group (CG) (N = 26) and evaluated for 12 weeks. The Asthma Control Test (ACT), Asthma Control Questionnaire (ACQ), Asthma Quality Life Questionnaire (AQLQ) and Beck Depression Inventory (BDI) questionnaires were applied. Spirometry, exhaled nitric oxide (NO), exhaled breath condensate (EBC) and induced sputum (IS), measurement of the peak flow and symptoms were performed. The IG patients received an educational activity for 30 min applied by a nurse. Statistical analysis: analysis of variance with repeated intragroup measures. IG presented a decreased number of eosinophils in IS and IL-17A in EBC, an increase in the percentage of FEV1 before and after bronchodilator and an improvement in quality of life compared to the CG. There was an improvement in depression levels and a decrease in IL-4 and IL-5 in the IS and in the EBC in both groups. Our results suggest that an educational intervention can bring benefits concerning the control of inflammation, lung function alterations, quality of life and levels of depression in asthmatic patients. Registration: ClinicalTrials.gov; NCT03655392.
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Affiliation(s)
- Soraia Nogueira Felix
- Instituto de Assistência Médica Ao Servidor Público Estadual (IAMSPE), Sao Paulo, SP, Brazil.
| | - Rosana Câmara Agondi
- Serviço de Imunologia Clínica e Alergia, HCFMUSP, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Marcelo Vivolo Aun
- Serviço de Imunologia Clínica e Alergia, HCFMUSP, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Clarice Rosa Olivo
- Instituto de Assistência Médica Ao Servidor Público Estadual (IAMSPE), Sao Paulo, SP, Brazil
- Universidade Cidade de Sao Paulo (UNICID), Sao Paulo, SP, Brazil
- Laboratório de Terapêutica Experimental (LIM-20), Faculdade de Medicina da USP (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Francine Maria de Almeida
- Laboratório de Terapêutica Experimental (LIM-20), Faculdade de Medicina da USP (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | | | | | - Pedro Giavina-Bianchi
- Serviço de Imunologia Clínica e Alergia, HCFMUSP, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | | | - Milton de Arruda de Martins
- Laboratório de Terapêutica Experimental (LIM-20), Faculdade de Medicina da USP (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Beatriz Mangueira Saraiva Romanholo
- Instituto de Assistência Médica Ao Servidor Público Estadual (IAMSPE), Sao Paulo, SP, Brazil.
- Universidade Cidade de Sao Paulo (UNICID), Sao Paulo, SP, Brazil.
- Laboratório de Terapêutica Experimental (LIM-20), Faculdade de Medicina da USP (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
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25
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How I do it. Work-up of severe asthma. Chest 2021; 160:2019-2029. [PMID: 34265308 DOI: 10.1016/j.chest.2021.07.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 07/03/2021] [Accepted: 07/06/2021] [Indexed: 11/22/2022] Open
Abstract
CASE EXAMPLE A 56-year-old gentleman has difficult to control asthma and a history of four exacerbations in the prior 12 months despite high-dose inhaled corticosteroids (ICS) and additional controller therapies. Is he suitable for more advanced therapeutic options? SCOPE OF REVIEW We herein review the clinical assessment of a patient with suspected severe asthma, discuss factors contributing to poor asthma control and how biomarkers assist in disease investigation and stratification. HOW I DO IT The key components of our multidisciplinary approach are to confirm an asthma diagnosis and adherence to treatment, to assess any contributing comorbidities or confounding factors, and to stratify what type of asthma our patient has. The combination of spirometry and repeated measures of key biomarkers of type-2 airway inflammation - the blood eosinophil count and fractional exhaled nitric oxide - identifies whether poor disease control is driven by uncontrolled, ICS-resistant type-2 airway inflammation or ongoing airflow obstruction. A failure to elicit evidence of either suggests an alternative driver for the patient's symptoms including chronic airway infection and non-asthma causes. Each phenotype represents a treatable trait that requires a specific targeted approach. Critically, steroids can cause harm and their use should be guided by objective evidence of inflammation rather than symptoms alone. CASE CONCLUSION After assessment of treatment adherence and exclusion of relevant comorbidities, the patient was found to have severe asthma with ICS-resistant type-2 airway inflammation. We will consider additional treatment options at our next appointment (Part 2/2 of this How I Do It series).
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26
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Maltby S, McDonald VM, Upham JW, Bowler SD, Chung LP, Denton EJ, Fingleton J, Garrett J, Grainge CL, Hew M, James AL, Jenkins C, Katsoulotos G, King GG, Langton D, Marks GB, Menzies-Gow A, Niven RM, Peters M, Reddel HK, Thien F, Thomas PS, Wark PAB, Yap E, Gibson PG. Severe asthma assessment, management and the organisation of care in Australia and New Zealand: expert forum roundtable meetings. Intern Med J 2021; 51:169-180. [PMID: 32104958 DOI: 10.1111/imj.14806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
Severe asthma imposes a significant burden on individuals, families and the healthcare system. Treatment is complex, due to disease heterogeneity, comorbidities and complexity in care pathways. New approaches and treatments improve health outcomes for people with severe asthma. However, emerging multidimensional and targeted treatment strategies require a reorganisation of asthma care. Consensus is required on how reorganisation should occur and what areas require further research. The Centre of Excellence in Severe Asthma convened three forums between 2015 and 2018, hosting experts from Australia, New Zealand and the UK. The forums were complemented by a survey of clinicians involved in the management of people with severe asthma. We sought to: (i) identify areas of consensus among experts; (ii) define activities and resources required for the implementation of findings into practice; and (iii) identify specific priority areas for future research. Discussions identified areas of unmet need including assessment and diagnosis of severe asthma, models of care and treatment pathways, add-on treatment approaches and patient perspectives. We recommend development of education and training activities, clinical resources and standards of care documents, increased stakeholder engagement and public awareness campaigns and improved access to infrastructure and funding. Further, we propose specific future research to inform clinical decision-making and develop novel therapies. A concerted effort is required from all stakeholders (including patients, healthcare professionals and organisations and government) to integrate new evidence-based practices into clinical care and to advance research to resolve questions relevant to improving outcomes for people with severe asthma.
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Affiliation(s)
- Steven Maltby
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - Vanessa M McDonald
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - John W Upham
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Department of Respiratory Medicine, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Simon D Bowler
- Immunity, Infection, and Inflammation Program, Mater Medical Research Institute, South Brisbane, Queensland, Australia
| | - Li P Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Eve J Denton
- Department of Respiratory Medicine, The Alfred Hospital and Austin Health, Melbourne, Victoria, Australia
| | - James Fingleton
- Capital and Coast District Health Board and Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Christopher L Grainge
- Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Mark Hew
- Department of Respiratory Medicine, The Alfred Hospital and Austin Health, Melbourne, Victoria, Australia
| | - Alan L James
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Australia and School of Medicine and Pharmacology, University of Western Australia, Western Australia, Australia
| | - Christine Jenkins
- Department of Thoracic Medicine, Concord Hospital, Concord Clinical School and Respiratory Discipline, University of Sydney, Concord, New South Wales, Australia.,The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, Liverpool, New South Wales, Australia
| | | | - Gregory G King
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - David Langton
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Department of Thoracic Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Guy B Marks
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, UNSW, Australia
| | | | - Robert M Niven
- Division of Infection, Immunity & Respiratory Medicine, Manchester Academic Health Science Centre and North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Matthew Peters
- Department of Thoracic Medicine, Concord Hospital, Concord, New South Wales, Australia
| | - Helen K Reddel
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Francis Thien
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Department of Respiratory Medicine, Eastern Health and Monash University, Box Hill, Victoria, Australia
| | - Paul S Thomas
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Peter A B Wark
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Elaine Yap
- Middlemore Hospital, Auckland, New Zealand
| | - Peter G Gibson
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
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27
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Abstract
PURPOSE OF REVIEW Severe asthma is often associated with numerous comorbidities that complicate disease management and affect patient's outcomes. They contribute to poor disease control and mimic asthma symptoms. Although some comorbidities such as obstructive sleep apnea, bronchiectasis, and chronic obstructive pulmonary disease are generally well recognized, many other may remain undiagnosed but may be detected in an expert specialist setting. The management of comorbidities seems to improve asthma outcomes, and optimizes therapy by avoiding overtreatment. The present review provides recent knowledge regarding the most common comorbidities which are associated with severe asthma. RECENT FINDINGS Comorbidities are more prevalent in severe asthma than in mild-to-moderate disease or in the general population. They can be grouped into two large domains: the pulmonary domain and the extrapulmonary domain. Pulmonary comorbidities include upper respiratory tract disorders (obstructive sleep apnea, allergic and nonallergic rhinitis, chronic rhinosinusitis, nasal polyposis) and middle/lower respiratory tract disorders (chronic obstructive pulmonary disease, allergic bronchopulmonary aspergillosis and fungal sensitization, bronchiectasis, dysfunctional breathing). Extrapulmonary comorbidities include anxiety, depression, gastro-esophageal reflux disease, obesity, cardiovascular, and metabolic diseases. SUMMARY The identification of comorbidities via multidimensional approach is needed to initiate appropriate multidisciplinary management of patients with severe asthma.
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28
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Stewart J, Kee F, Hart N. Using routinely collected primary care records to identify and investigate severe asthma: a scoping review. NPJ Prim Care Respir Med 2021; 31:1. [PMID: 33500422 PMCID: PMC7838272 DOI: 10.1038/s41533-020-00213-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/24/2020] [Indexed: 12/30/2022] Open
Abstract
Shielding during the coronavirus pandemic has highlighted the potential of routinely collected primary care records to identify patients with 'high-risk' conditions, including severe asthma. We aimed to determine how previous studies have used primary care records to identify and investigate severe asthma and whether linkage to other data sources is required to fully investigate this 'high-risk' disease variant. A scoping review was conducted based on the Arksey and O'Malley framework. Twelve studies met all criteria for inclusion. We identified variation in how studies defined the background asthma cohort, asthma severity, control and clinical outcomes. Certain asthma outcomes could only be investigated through linkage to secondary care records. The ability of primary care records to represent the entire known asthma population is unique. However, a number of challenges need to be overcome if their full potential to accurately identify and investigate severe asthma is to be realised.
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Affiliation(s)
- Jonathan Stewart
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Science, Block A, Royal Victoria Hospital, Belfast, BT12 6BA, UK.
| | - Frank Kee
- Centre for Public Health, Queen's University Belfast, Institute of Clinical Science, Block A, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - Nigel Hart
- Centre for Medical Education, Queen's University Belfast, Whitla Medical Building, 97 Lisburn Road, Belfast, BT9 7BL, UK
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29
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Mayoral K, Garin O, Caballero-Rabasco MA, Praena-Crespo M, Bercedo A, Hernandez G, Castillo J, Lizano Barrantes C, Pardo Y, Ferrer M. Smartphone App for monitoring Asthma in children and adolescents. Qual Life Res 2021; 30:3127-3144. [PMID: 33387290 DOI: 10.1007/s11136-020-02706-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 01/04/2023]
Abstract
PURPOSE The asthma stepwise treatment approach recommended is based on monitoring patients' symptoms. The Asthma Research in Children and Adolescents (ARCA) cohort was created to provide evidence about the evolution of persistent asthma. This manuscript describes the development of an electronic health tool, comprising a mobile health application for patients with asthma and its associated online platform for pediatricians to monitor them. METHODS The development process followed 7 phases: the first 5 (Conceptualization, Preparation, Assessment scheduling, Image and user interface, and Technical development) defined and designed the tool, followed by a testing phase (functionality assessment and pilot test with ARCA patients), and a last phase which evaluated usability. Since the target population was aged 6-16 years, three versions were designed within the same smartphone application: parents/proxy, children, and adolescents. The online platform for pediatricians provides real-time information from the application: patients' responses over time with color-coded charts (red/amber/green, as in traffic lights). RESULTS The pilot test through semi-structured phone interviews of the first 50 participants included in the ARCA study (n = 53) detected their misunderstandings. Pediatricians were trained to emphasize that the application is free of charge and requires monthly answers. Median of the System Usability Scale scores (n = 85), ranging 0 (negative)-100 (positive), was > 93 in the three age versions of the application. CONCLUSIONS Technology has the capability of transforming the use of patient-reported outcomes. Describing all the development phases of a mobile health application for monitoring children and adolescents with asthma may increase the knowledge on how to design applications for young patients.
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Affiliation(s)
- K Mayoral
- Health Services Research Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.,Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública CIBERESP, Madrid, Spain
| | - O Garin
- Health Services Research Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain. .,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública CIBERESP, Madrid, Spain. .,Pompeu Fabra University UPF, Barcelona, Spain.
| | - M A Caballero-Rabasco
- Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Pediatric Allergy and Pulmonology Unit, Pediatric Service, Hospital del Mar, Barcelona, Spain
| | - M Praena-Crespo
- Centro de Salud la Candelaria, Servicio Andaluz de Salud, Seville, Spain.,Grupo de Vías Respiratorias de la Asociación Española de Pediatras de Atención Primaria (AEPAP), Madrid, Spain
| | - A Bercedo
- Grupo de Vías Respiratorias de la Asociación Española de Pediatras de Atención Primaria (AEPAP), Madrid, Spain.,Centro de Salud Dobra, Servicio Cántabro de Salud, Cantabria, Spain
| | - G Hernandez
- Grupo de Vías Respiratorias de la Asociación Española de Pediatras de Atención Primaria (AEPAP), Madrid, Spain.,CAP Vila Olimpica, Parc Sanitari Pere Virgili, Barcelona, Spain
| | - J Castillo
- Grupo de Vías Respiratorias de la Asociación Española de Pediatras de Atención Primaria (AEPAP), Madrid, Spain.,Pediatric Pneumology Unit, Pediatric Service, Hospital Infantil Universitario Miguel Servet, Zaragoza, Spain
| | - C Lizano Barrantes
- Health Services Research Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.,Pompeu Fabra University UPF, Barcelona, Spain.,University of Costa Rica, San José, Costa Rica
| | - Y Pardo
- Health Services Research Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública CIBERESP, Madrid, Spain.,Department of Psychiatry and Legal Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Ferrer
- Health Services Research Group, IMIM-Hospital del Mar Medical Research Institute, Barcelona, Spain. .,Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain. .,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública CIBERESP, Madrid, Spain.
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30
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Abstract
Background: Severe asthma is a heterogeneous disease that consists of various phenotypes driven by different pathways. Associated with significant morbidity, an important negative impact on the quality of life of patients, and increased health care costs, severe asthma represents a challenge for the clinician. With the introduction of various antibodies that target type 2 inflammation (T2) pathways, severe asthma therapy is gradually moving to a personalized medicine approach. Objective: The purpose of this review was to emphasize the important role of personalized medicine in adult severe asthma management. Methods: An extensive research was conducted in medical literature data bases by applying terms such as "severe asthma" associated with "structured approach," "comorbidities," "biomarkers," "phenotypes/endotypes," and "biologic therapies." Results: The management of severe asthma starts with a structured approach to confirm the diagnosis, assess the adherence to medications and identify confounding factors and comorbidities. The definition of phenotypes or endotypes (phenotypes defined by mechanisms and identified through biomarkers) is an important step toward the use of personalized medicine in asthma. Severe allergic and nonallergic eosinophilic asthma are two defined T2 phenotypes for which there are efficacious targeted biologic therapies currently available. Non-T2 phenotype remains to be characterized, and less efficient target therapy exists. Conclusion: Despite important progress in applying personalized medicine to severe asthma, especially in T2 inflammatory phenotypes, future research is needed to find valid biomarkers predictive for the response to available biologic therapies to develop more effective therapies in non-T2 phenotype.
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Affiliation(s)
- Angelica Tiotiu
- From the Department of Pulmonology, University Hospital of Nancy, Nancy, France; and
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31
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Ryan D, Heatley H, Heaney LG, Jackson DJ, Pfeffer PE, Busby J, Menzies-Gow AN, Jones R, Tran TN, Al-Ahmad M, Backer V, Belhassen M, Bosnic-Anticevich S, Bourdin A, Bulathsinhala L, Carter V, Chaudhry I, Eleangovan N, FitzGerald JM, Gibson PG, Hosseini N, Kaplan A, Murray RB, Rhee CK, Van Ganse E, Price DB. Potential Severe Asthma Hidden in UK Primary Care. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1612-1623.e9. [PMID: 33309935 DOI: 10.1016/j.jaip.2020.11.053] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Severe asthma may be underrecognized in primary care. OBJECTIVE Identify and quantify patients with potential severe asthma (PSA) in UK primary care, the proportion not referred, and compare primary care patients with PSA with patients with confirmed severe asthma from UK tertiary care. METHODS This was a historical cohort study including patients from the Optimum Patient Care Research Database (aged ≥16 years, active asthma diagnosis pre-2014) and UK patients in the International Severe Asthma Registry (UK-ISAR aged ≥18 years, confirmed severe asthma in tertiary care). In the OPCRD, PSA was defined as Global INitiative for Asthma 2018 step 4 treatment and 2 or more exacerbations/y or at Global INitiative for Asthma step 5. The proportion of these patients and their referral status in the last year were quantified. Demographic and clinical characteristics of groups were compared. RESULTS Of 207,557 Optimum Patient Care Research Database patients with asthma, 16,409 (8%) had PSA. Of these, 72% had no referral/specialist review in the past year. Referred patients with PSA tended to have greater prevalence of inhaled corticosteroid/long-acting β2-agonist add-ons (54.1 vs 39.8%), and experienced significantly (P < .001) more exacerbations per year (median, 3 vs 2/y), worse asthma control, and worse lung function (% predicted postbronchodilator FEV1/forced vital capacity, 0.69 vs 0.72) versus nonreferred patients. Confirmed patients with severe asthma (ie, UK patients in the International Severe Asthma Registry) were younger (51 vs 65 years; P < .001), and significantly (P < .001) more likely to have uncontrolled asthma (91.4% vs 62.5%), a higher exacerbation rate (4/y [initial assessment] vs 3/y), use inhaled corticosteroid/long-acting β2-agonist add-ons (67.7% vs 54.1%), and have nasal polyposis (24.2% vs 6.8) than referred patients with PSA. CONCLUSIONS Large numbers of patients with PSA in the United Kingdom are underrecognized in primary care. These patients would benefit from a more systematic assessment in primary care and possible specialist referral.
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Affiliation(s)
- Dermot Ryan
- Usher Institute, University of Edinburgh, United Kingdom
| | - Heath Heatley
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Liam G Heaney
- UK Severe Asthma Network and National Registry, Queen's University Belfast, Belfast, Northern Ireland
| | - David J Jackson
- UK Severe Asthma Network and National Registry, Guy's and St Thomas' NHS Trust and Division of Asthma, Allergy & Lung Biology, King's College London, London, United Kingdom
| | - Paul E Pfeffer
- UK Severe Asthma Network, Barts Health NHS Trust and Queen Mary University of London, London, United Kingdom
| | - John Busby
- UK Severe Asthma Network and National Registry, Queen's University Belfast, Belfast, Northern Ireland
| | - Andrew N Menzies-Gow
- UK Severe Asthma Network and National Registry, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Rupert Jones
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | | | - Mona Al-Ahmad
- Al-Rashed Allergy Center, Ministry of Health, Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait
| | - Vibeke Backer
- Department of ENT & Centre for Physical Activity Research, Rigshospitalet and Copenhagen University, Copenhagen, Denmark
| | - Manon Belhassen
- PELyon, HESPER 7425, Claude Bernard University, Lyon, France
| | - Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney and Sydney Local Health District, Glebe, NSW, Australia
| | - Arnaud Bourdin
- Department of Respiratory Diseases, Montpellier University Hospitals, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Lakmini Bulathsinhala
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | - Isha Chaudhry
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Neva Eleangovan
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | | | - Peter G Gibson
- Australian Severe Asthma Network, Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, NSW, Australia; Hunter Medical Research Institute, Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | | | - Alan Kaplan
- Family Physician Airways Group of Canada, Stouffville, ON, Canada; University of Toronto, Toronto, ON, Canada
| | | | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eric Van Ganse
- PELyon, HESPER 7425, Claude Bernard University, Lyon, France
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.
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Jackson DJ, Busby J, Pfeffer PE, Menzies-Gow A, Brown T, Gore R, Doherty M, Mansur AH, Message S, Niven R, Patel M, Heaney LG. Characterisation of patients with severe asthma in the UK Severe Asthma Registry in the biologic era. Thorax 2020; 76:220-227. [PMID: 33298582 PMCID: PMC7892381 DOI: 10.1136/thoraxjnl-2020-215168] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 09/15/2020] [Accepted: 10/14/2020] [Indexed: 02/06/2023]
Abstract
Background The UK Severe Asthma Registry (UKSAR) is the world’s largest national severe asthma registry collecting standardised data on referrals to UK specialist services. Novel biologic therapies have transformed the management of type 2(T2)-high severe asthma but have highlighted unmet need in patients with persisting symptoms despite suppression of T2-cytokine pathways with corticosteroids. Methods Demographic, clinical and treatments characteristics for patients meeting European Respiratory Society / American Thoracic Society severe asthma criteria were examined for 2225 patients attending 15 specialist severe asthma centres. We assessed differences in biomarker low patients (fractional exhaled nitric oxide (FeNO) <25 ppb, blood eosinophils <150/μL) compared with a biomarker high population (FeNO ≥25 ppb, blood eosinophils ≥150/µL). Results Age (mean 49.6 (14.3) y), age of asthma onset (24.2 (19.1) y) and female predominance (62.4%) were consistent with prior severe asthma cohorts. Poor symptom control (Asthma Control Questionnaire-6: 2.9 (1.4)) with high exacerbation rate (4 (IQR: 2, 7)) were common despite high-dose treatment (51.7% on maintenance oral corticosteroids (mOCS)). 68.9% were prescribed biologic therapies including mepolizumab (50.3%), benralizumab (26.1%) and omalizumab (22.6%). T2-low patients had higher body mass index (32.1 vs 30.2, p<0.001), depression/anxiety prevalence (12.3% vs 7.6%, p=0.04) and mOCS use (57.9% vs 42.1%, p<0.001). Many T2-low asthmatics had evidence of a historically elevated blood eosinophil count (0.35 (0.13, 0.60)). Conclusions The UKSAR describes the characteristics of a large cohort of asthmatics referred to UK specialist severe asthma services. It offers the prospect of providing novel insights across a range of research areas and highlights substantial unmet need with poor asthma control, impaired lung function and high exacerbation rates. T2-high phenotypes predominate with significant differences apparent from T2-low patients. However, T2-low patients frequently have prior blood eosinophilia consistent with possible excessive corticosteroid exposure.
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Affiliation(s)
- David J Jackson
- Guy's Severe Asthma Centre, Guy's and St Thomas' NHS Foundation Trust, UK.,Asthma UK Centre, King's College London, UK
| | - John Busby
- Centre for Public Health, Queen's University Belfast School of Medicine, Dentistry and Biomedical Sciences, UK
| | - Paul E Pfeffer
- Respiratory Medicine, Barts Health NHS Trust, London, UK
| | - Andrew Menzies-Gow
- Lung Division, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Thomas Brown
- Respiratory Medicine, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Robin Gore
- Respiratory Medicine, Cambridge University Hospitals Trust, Cambridge, UK
| | - Martin Doherty
- Respiratory Medicine, Russells Hall Hospital, Dudley, UK
| | - Adel H Mansur
- Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, UK.,University of Birmingham, UK
| | - Simon Message
- Respiratory Medicine, Gloucestershore Royal Hospital, Gluocester, UK
| | - Robert Niven
- Wythenshawe Hospital, Manchester NHS Foundation Trust, UK
| | - Mitesh Patel
- Respiratory Medicine, University Plymouth NHS Trust, Plymouth, UK
| | - Liam G Heaney
- Centre for Experimental Medicine, Queen's University Belfast School of Medicine, Dentistry and Biomedical Sciences, UK .,Belfast Health & Social Care NHS Trust, UK
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33
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Feng M, Zhang X, Wu WW, Chen ZH, Oliver BG, McDonald VM, Zhang HP, Xie M, Qin L, Zhang J, Wang L, Li WM, Wang G, Gibson PG. Clinical and Inflammatory Features of Exacerbation-Prone Asthma: A Cross-Sectional Study Using Multidimensional Assessment. Respiration 2020; 99:1109-1121. [PMID: 33271561 DOI: 10.1159/000510793] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 08/06/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Reducing asthma exacerbations is a major target of current clinical guidelines, but identifying features of exacerbation-prone asthma (EPA) using multidimensional assessment (MDA) is lacking. OBJECTIVE To systemically explore the clinical and inflammatory features of adults with EPA in a Chinese population. METHODS We designed a cross-sectional study using the Severe Asthma Web-based Database from the Australasian Severe Asthma Network (ASAN). Eligible Chinese adults with asthma (n = 546) were assessed using MDA. We stratified patients based on exacerbation frequency: none, few (1 or 2), and exacerbation prone (≥3). Univariate and multivariable negative binomial regression analyses were performed to investigate features associated with the frequency of exacerbations. RESULTS Of 546 participants, 61.9% had no exacerbations (n = 338), 29.6% had few exacerbations (n = 162), and 8.4% were exacerbation prone (n = 46) within the preceding year. EPA patients were characterized by elevated blood and sputum eosinophils but less atopy, with more controller therapies but worse asthma control and quality of life (all p < 0.05). In multivariable models, blood and sputum eosinophils (adjusted rate ratio = 2.23, 95% confidence interval = [1.26, 3.84] and 1.67 [1.27, 2.21], respectively), FEV1 (0.90 [0.84, 0.96]), bronchodilator responsiveness (1.16 [1.05, 1.27]), COPD (2.22 [1.41, 3.51]), bronchiectasis (2.87 [1.69, 4.89]), anxiety (2.56 [1.10, 5.95]), and depression (1.94 [1.20, 3.13]) were found. Further, upper respiratory tract infection (1.83 [1.32, 2.54]) and food allergy (1.67 [1.23, 2.25]) were at high risk of asthma symptom triggers. CONCLUSION EPA is a clinically recognizable phenotype associated with several recognizable traits that could be addressed by targeted treatment.
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Affiliation(s)
- Min Feng
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Xin Zhang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Wen Wen Wu
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Zhi Hong Chen
- Shanghai Institute of Respiratory Disease, Respiratory Division of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Brian G Oliver
- School of Life Sciences, University of Technology Sydney, Ultimo, New South Wales, Australia.,Respiratory Cellular and Molecule Biology, Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Vanessa M McDonald
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Hong Ping Zhang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Min Xie
- Department of Respiratory and Critical Care Medicine, Tongji Hospital, Huazhong University of Science & Technology, Wuhan, China
| | - Ling Qin
- Department of Respiratory and Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Jie Zhang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Jilin University, Changchun, China
| | - Lei Wang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China.,Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China
| | - Wei Min Li
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Gang Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China, .,Laboratory of Pulmonary Immunology and Inflammation, Frontiers Science Center for Disease-related Molecular Network, Sichuan University, Chengdu, China,
| | - Peter G Gibson
- Priority Research Centre for Healthy Lungs, Hunter Medical Research Institute, The University of Newcastle, Newcastle, New South Wales, Australia
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34
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Leibel S, Geng B, Phipatanakul W, Lee E, Hartigan P. Screening Social Determinants of Health in a Multidisciplinary Severe Asthma Clinical Program. Pediatr Qual Saf 2020; 5:e360. [PMID: 33204931 PMCID: PMC7665245 DOI: 10.1097/pq9.0000000000000360] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 08/06/2020] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. Asthma is the most common cause of chronic disease in children and has high healthcare utilization costs. Minority children living in poverty have a higher asthma burden. These health disparities are associated with the social determinants of health (SDH). A severe asthma clinic was implemented at Rady Children’s Hospital in San Diego to determine whether a multidisciplinary approach, including an asthma home visit addressing SDH, would lead to decreased healthcare utilization in terms of emergency department (ED) visits and hospitalizations.
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Affiliation(s)
- Sydney Leibel
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, UC San Diego School of Medicine/Rady Children's Hospital, San Diego, Calif
| | - Bob Geng
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, UC San Diego School of Medicine/Rady Children's Hospital, San Diego, Calif
| | - Wanda Phipatanakul
- Division of Asthma, Allergy and Immunology, Department of Pediatrics, Harvard Medical School/Boston Children's Hospital, Boston, Mass
| | - Euyhyun Lee
- Altman Clinical and Translational Research Institute, UC San Diego, San Diego, Calif
| | - Phyllis Hartigan
- Center for Healthier Communities, Rady Children's Hospital, San Diego, Calif
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35
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Scichilone N, Barnes PJ, Battaglia S, Benfante A, Brown R, Canonica GW, Caramori G, Cazzola M, Centanni S, Cianferoni A, Corsico A, De Carlo G, Di Marco F, Gaga M, Hawrylowicz C, Heffler E, Matera MG, Matucci A, Paggiaro P, Papi A, Popov T, Rogliani P, Santus P, Solidoro P, Togias A, Boulet LP. The Hidden Burden of Severe Asthma: From Patient Perspective to New Opportunities for Clinicians. J Clin Med 2020; 9:jcm9082397. [PMID: 32727032 PMCID: PMC7463666 DOI: 10.3390/jcm9082397] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022] Open
Abstract
Severe asthma is an important topic in respiratory diseases, due to its high impact on morbidity and mortality as well as on health-care resources. The many challenges that still exist in the management of the most difficult-to-treat forms of the disease, and the acknowledgement of the existence of unexplored areas in the pathophysiological mechanisms and the therapeutic targets represent an opportunity to gather experts in the field with the immediate goals to summarize current understanding about the natural history of severe asthma and to identify gaps in knowledge and research opportunities, with the aim to contribute to improved medical care and health outcomes. This article is a consensus document from the “International Course on Severe Asthma” that took place in Palermo, Italy, on May 10–11, 2019. Emerging topics in severe asthma were addressed and discussed among experts, with special focus on patient’s needs and research opportunities, with the aim to highlight the unanswered questions in the diagnostic process and therapeutic approach.
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Affiliation(s)
- Nicola Scichilone
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
- Correspondence: ; Tel.: +39-091-655-2146
| | - Peter John Barnes
- Airway Disease Section, National Heart & Lung Institute, Imperial College London, Dovehouse Street, London SW3 6LY, UK;
| | - Salvatore Battaglia
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
| | - Alida Benfante
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
| | - Robert Brown
- Department of Anesthesiology and Critical Care Medicine, Medicine, Department of Medicine, Division of Pulmonary Medicine, Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, MD 21287, USA;
| | - Giorgio Walter Canonica
- Personalised Medicine Clinic Asthma & Allergy, Humanitas University, Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (G.W.C.); (E.H.)
| | - Gaetano Caramori
- Respiratory Medicine Unit, Department of Biomedical Sciences, Dentistry and Morphological and Functional Imaging (BIOMORF), University of Messina, 98122 Messina, Italy;
| | - Mario Cazzola
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (M.C.); (P.R.)
| | - Stefano Centanni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, 20142 Milan, Italy;
| | - Antonella Cianferoni
- Pediatrics Department, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Angelo Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics – University of Pavia, 27100 Pavia, Italy;
| | - Giuseppe De Carlo
- The European Federation of Allergy and Airways Diseases Patients Associations (EFA), 1000 Brussels, Belgium;
| | - Fabiano Di Marco
- Respiratory Unit, ASST - Papa Giovanni XXIII Hospital, Bergamo, University of Milan, 24127 Milan, Italy;
| | - Mina Gaga
- 7th Respiratory Medicine Dept, Asthma Cen, Athens Chest Hospital, 11527 Athens, Greece;
| | - Catherine Hawrylowicz
- Division of Asthma, Allergy and Lung Biology, King’s College London, Guy’s Hospital, London SE1 9RT, UK;
| | - Enrico Heffler
- Personalised Medicine Clinic Asthma & Allergy, Humanitas University, Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (G.W.C.); (E.H.)
| | - Maria Gabriella Matera
- Unit of Pharmacology, Dept. Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Andrea Matucci
- Immunoallergology Unit, Careggi University Hospital, 50139 Florence, Italy;
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, 56126 Pisa, Italy;
| | - Alberto Papi
- Research Center on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Todor Popov
- Clinic of Occupational Diseases, University Hospital Sv. Ivan Rilski, 1431 Sofia, Bulgaria;
| | - Paola Rogliani
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (M.C.); (P.R.)
| | - Pierachille Santus
- Division of Respiratory Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy;
| | - Paolo Solidoro
- Pneumology Unit U, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, University of Turin, 10126 Turin, Italy;
| | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, Bethesda, MD 20814, USA;
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36
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The Challenges and Opportunities of Maximizing the Benefits of Severe Asthma Registries. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:1469-1470. [PMID: 31076060 DOI: 10.1016/j.jaip.2018.11.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 11/16/2018] [Indexed: 11/20/2022]
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37
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Bleecker ER, Menzies-Gow AN, Price DB, Bourdin A, Sweet S, Martin AL, Alacqua M, Tran TN. Systematic Literature Review of Systemic Corticosteroid Use for Asthma Management. Am J Respir Crit Care Med 2020; 201:276-293. [PMID: 31525297 PMCID: PMC6999108 DOI: 10.1164/rccm.201904-0903so] [Citation(s) in RCA: 169] [Impact Index Per Article: 42.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Systemic corticosteroid use to manage uncontrolled asthma and its associated healthcare burden may account for important health-related adverse effects. We conducted a systematic literature review to investigate the real-world extent and burden of systemic corticosteroid use in asthma. We searched MEDLINE and Embase databases to identify English-language articles published in 2010–2017, using search terms for asthma with keywords for oral corticosteroids and systemic corticosteroids. Observational studies, prescription database analyses, economic analyses, and surveys on oral/systemic corticosteroid use in children (>5 yr old), adolescents (12–17 yr old), and adults with asthma were included. We identified and reviewed 387 full-text articles, and our review included data from 139 studies. The included studies were conducted in Europe, North America, and Asia. Overall, oral/systemic corticosteroids were commonly used for asthma management and were more frequently used in patients with severe asthma than in those with milder disease. Long-term oral/systemic corticosteroid use was, in general, less frequent than short-term use. Compared with no use, long-term and repeated short-term oral/systemic corticosteroid use were associated with an increased risk of acute and chronic adverse events, even when doses were comparatively low. Greater oral/systemic corticosteroid exposure was also associated with increased costs and healthcare resource use. This review provides a comprehensive overview of oral/systemic corticosteroid use and associated adverse events for patients with all degrees of asthma severity and exposure duration. We report that oral/systemic corticosteroid use is prevalent in asthma management, and the risks of acute and chronic complications increase with the cumulative oral corticosteroid dosage.
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Affiliation(s)
- Eugene R Bleecker
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona Health Sciences, Tucson, Arizona
| | | | - David B Price
- Department of Primary Care Respiratory Medicine, University of Aberdeen, Aberdeen, United Kingdom.,Observational and Pragmatic Research Institute, Singapore
| | - Arnaud Bourdin
- Department of Respiratory Diseases, University of Montpellier, Montpellier, France
| | - Stephen Sweet
- Research Evaluation Unit, Oxford PharmaGenesis Ltd., Oxford, United Kingdom
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38
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Maltby S, Gibson PG, Reddel HK, Smith L, Wark PAB, King GG, Upham JW, Clark VL, Hew M, Owens L, Oo S, James AL, Thompson B, Marks GB, McDonald VM. Severe Asthma Toolkit: an online resource for multidisciplinary health professionals-needs assessment, development process and user analytics with survey feedback. BMJ Open 2020; 10:e032877. [PMID: 32209622 PMCID: PMC7202709 DOI: 10.1136/bmjopen-2019-032877] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Severe asthma imposes a significant burden on individuals, families and the healthcare system. New treatment and management approaches are emerging as effective options for severe asthma. Translating new knowledge to multidisciplinary healthcare professionals is a priority. We developed 'The Severe Asthma Toolkit' (https://toolkit.severeasthma.org.au) to increase awareness of severe asthma, provide evidence-based resources and support decisionmaking by healthcare providers. SETTING Roundtable discussions and a survey of Australians clinicians were conducted to determine clinician preferences, format and content for a severe asthma resource. PARTICIPANTS A reference group from stakeholder and consumer bodies and severe asthma experts provided advice and feedback. A multidisciplinary team of international experts was engaged to develop content. Written content was based on up-to-date literature. Peer and editorial review were performed to finalise content and inform web design. Website design focused on user experience, navigation, engagement, interactivity and tailoring of content for a clinical audience. RESULTS A web-based resource was developed. Roundtable discussions and a needs assessment survey identified the need for dedicated severe asthma management resources to support skills training. The end-product, which launched 26 March 2018, includes an overview of severe asthma, diagnosis and assessment, management, medications, comorbidities, living with severe asthma, establishing a clinic, paediatrics/adolescents and clinical resources. Analytics indicate access by users worldwide (32 169 users from 169 countries). User survey results (n=394) confirm access by the target audience (72% health professionals), who agreed the toolkit increased their knowledge (73%) and confidence in managing severe asthma (66%), and 75% are likely to use the resource in clinic. CONCLUSIONS The Severe Asthma Toolkit is a unique, evidence-based internet resource to support healthcare professionals providing optimal care for people with severe asthma. It is a comprehensive, accessible and independent resource developed by leading severe asthma experts to improve clinician knowledge and skills in severe asthma management.
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Affiliation(s)
- Steven Maltby
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Peter G Gibson
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Helen K Reddel
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Lorraine Smith
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- School of Pharmacy, University of Sydney Faculty of Pharmacy, Sydney, New South Wales, Australia
| | - Peter A B Wark
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Gregory G King
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - John W Upham
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Department of Respiratory Medicine, Princess Alexandra Hospital TRI, South Brisbane, Queensland, Australia
| | - Vanessa L Clark
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
| | - Mark Hew
- Department of Allergy, Immunology & Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Louisa Owens
- Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Stephen Oo
- Princess Margaret Hospital, Fiona Stanley Hospital and University of Western Australia, Perth, New South Wales, Australia
| | - Alan L James
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Bruce Thompson
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Guy B Marks
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
- South Western Sydney Clinical School UNSW, Sydney, New South Wales, Australia
| | - Vanessa M McDonald
- NHMRC Centre of Excellence in Severe Asthma, New Lambton, New South Wales, Australia
- Priority Research Centre for Healthy Lungs, University of Newcastle, Callaghan, New South Wales, Australia
- Hunter Medical Research Institute, New Lambton Heights, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
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39
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Hew M, Menzies-Gow A, Hull JH, Fleming L, Porsbjerg C, Brinke AT, Allen D, Gore R, Tay TR. Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2222-2233. [PMID: 32173508 DOI: 10.1016/j.jaip.2020.02.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Difficult-to-treat asthma affects a minority of adults and children with asthma but represents a challenging mix of misdiagnosis, multimorbidity, inadequate self-management, severe airway pathobiology, and treatment complications. Management of these patients extends beyond asthma pharmacotherapy, because multiple other patient-related domains need to be addressed as well. Such complexity can hinder adequate clinical assessment even when performed in specialist practice. Systematic assessment undertaken by specialized multidisciplinary teams brings a broad range of resources to bear on patients with difficult-to-treat asthma. Although the concept of systematic assessment is not new, practices vary considerably and implementation is not universal. Nevertheless, assessment protocols are already in place in several institutions worldwide, and outcomes after such assessments have been highly encouraging. This review discusses the rationale, components, and benefits of systematic assessment, outlining its clinical utility and the available evidence for improved outcomes. It describes a range of service configurations and assessment approaches, drawing examples from severe asthma centers around the world to highlight common essential elements. It also provides a framework for establishing such services and discusses practical considerations for implementation.
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Affiliation(s)
- Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Andrew Menzies-Gow
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James H Hull
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Paediatric Difficult Asthma Service, Royal Brompton Hospital, London, United Kingdom
| | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anneke Ten Brinke
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - David Allen
- North West Lung Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Robin Gore
- Department of Respiratory Medicine, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
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Mosquera RA, Caramel Avritscher EB, Yadav A, Pedroza C, Samuels CL, Harris TS, Tetzlaff C, Eapen J, Gonzales TR, Green C, Tyson JE. Unexpected results of a randomized quality improvement program for children with severe asthma. J Asthma 2020; 58:596-603. [PMID: 31994954 DOI: 10.1080/02770903.2020.1723621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To assess whether an asthma intervention program reduces treatment days outside the home among children with severe asthma receiving comprehensive care (CC) in our center.Methods: Between October 21, 2014 and September 28, 2016, children with severe asthma were randomized to receive CC alone (n = 29) or CC plus the asthma intervention program (n = 34) which involved collaboration with pharmacists and school nurses, motivational interviewing, and tracking the one-second forced expiratory volume at home. All patients were followed through March 31, 2017. Frequentist and Bayesian intent-to-treat analyses were performed.Results: The asthma intervention program doubled the telephone calls between the staff and families (753 vs 356 per 100 child years for the intervention group vs. control group; Rate Ratio [RR], 2.11 [95% confidence interval, 1.29-3.45]). Yet, we found no evidence that it reduced the composite number of days of healthcare outside home which includes: clinic visits, ED visits, and hospital admissions (1179 vs 958 per 100 child-years in the intervention group vs. control group; [RR], 1.23 [95% CI, 0.82-1.84]) or secondary outcomes which are individual components (clinic visits, ED visits, hospitalizations, PICU admissions and school absences; RR 1.15 - 2.30; p > 0.05). Bayesian analysis indicated a 67% probability that the intervention program increases total treatment days outside the home and only a 14% probability of a true decrease of >20% as originally hypothesized.Conclusion: A multi-component intervention program provided to children with severe asthma failed to reduce and may have increased days of healthcare outside home and school absenteeism.
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Affiliation(s)
- Ricardo A Mosquera
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Elenir B Caramel Avritscher
- Center of Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Aravind Yadav
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Claudia Pedroza
- Center of Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Cheryl L Samuels
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Tomika S Harris
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Cecilia Tetzlaff
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Julie Eapen
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Traci R Gonzales
- Department of Pediatrics, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Charles Green
- Center of Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jon E Tyson
- Center of Clinical Research and Evidence-Based Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Systematic Assessment for Difficult and Severe Asthma Improves Outcomes and Halves Oral Corticosteroid Burden Independent of Monoclonal Biologic Use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1616-1624. [PMID: 31954193 DOI: 10.1016/j.jaip.2019.12.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/22/2019] [Accepted: 12/28/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Guidelines endorse systematic assessment for severe asthma, with data indicating benefit across multiple outcome domains. OBJECTIVE We examined which patients respond to systematic assessment and whether oral corticosteroid burden can be decreased independent of monoclonal biologic use. METHODS Specialist-referred patients are assessed systematically for difficult asthma at our center. We undertook a responder analysis for improvements in the domains of symptom control, quality of life, exacerbations, and airflow obstruction, assessed 6 months after initial assessment. Multivariate analyses were performed for each domain to identify predictors of response. Changes in oral corticosteroid burden were also measured, stratified by monoclonal biologics commenced during assessment. RESULTS Among 161 patients assessed systematically, 64% had a reduction in exacerbations, 54% achieved minimum clinically important differences for both symptom control and quality of life, and 40% increased their forced expiratory volume in 1 second by ≥100 mL. Altogether, 87% of patients with asthma improved in at least 1 domain. The most consistent predictor of response across domains was poorer baseline asthma status. There was a substantial reduction in mean chronic oral corticosteroid dose (11-5 mg, n = 46, P < .001), even after excluding 7 patients commenced on monoclonal biologics (11-5.6 mg, n = 39, P < .001). CONCLUSIONS Almost 90% of patients undergoing systematic assessment for difficult asthma improve significantly in at least 1 key asthma outcome, with few reliable predictors of response. The halving of oral corticosteroid burden during systematic assessment is independent of, and comparable in magnitude with, that achieved by monoclonal biologics.
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42
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Chung LP, Upham JW, Bardin PG, Hew M. Rational oral corticosteroid use in adult severe asthma: A narrative review. Respirology 2019; 25:161-172. [PMID: 31713955 PMCID: PMC7027745 DOI: 10.1111/resp.13730] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/05/2019] [Accepted: 10/22/2019] [Indexed: 12/17/2022]
Abstract
OCS play an important role in the management of asthma. However, steroid‐related AE are common and represent a leading cause of morbidity. Limited published studies suggest OCS usage varies across countries and recent registry data indicate that at least 25–60% of patients with severe asthma in developed countries may at some stage be prescribed OCS. Recent evidence indicate that many patients do not receive optimal therapy for asthma and are often prescribed maintenance OCS or repeated steroid bursts to treat exacerbations. Given the recent progress in adult severe asthma and new treatment options, judicious appraisal of steroid use is merited. A number of strategies and add‐on therapies are now available to treat severe asthma. These include increasing specialist referral for multidisciplinary assessments and implementing OCS‐sparing interventions, such as improving guideline adherence and add‐on tiotropium and macrolides. Biologics have recently become available for severe asthma; these agents reduce asthma exacerbations and lower OCS exposure. Further research, collaboration and consensus are necessary to develop a structured stewardship approach including realistic OCS‐weaning programmes for patients with severe asthma on regular OCS; education and public health campaigns to improve timely access to specialized severe asthma services for treatment optimization; and implementing targeted strategies to identify patients who warrant OCS use using objective biomarker‐based strategies.
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Affiliation(s)
- Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - John W Upham
- Department of Respiratory Medicine, Princess Alexandra Hospital and University of Queensland, Brisbane, QLD, Australia
| | - Philip G Bardin
- Department of Respiratory and Sleep Medicine, Monash Medical Centre, Monash University, Melbourne, VIC, Australia
| | - Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Hospital, Melbourne, VIC, Australia
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43
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Bègne C, Justet A, Dupin C, Taillé C. Evaluation in a severe asthma expert center improves asthma outcomes regardless of step-up in asthma therapy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:1439-1442.e2. [PMID: 31706047 DOI: 10.1016/j.jaip.2019.10.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 10/08/2019] [Accepted: 10/14/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Camille Bègne
- Service de Pneumologie et Centre de Référence Constitutif des Maladies Pulmonaires Rares, Hôpital Bichat, Groupe Hospitalier Universitaire AP-HP Nord- Université de Paris, Paris, France
| | - Aurélien Justet
- Service de Pneumologie et Centre de Référence Constitutif des Maladies Pulmonaires Rares, Hôpital Bichat, Groupe Hospitalier Universitaire AP-HP Nord- Université de Paris, Paris, France; INSERM UMR 1152, LabEx Inflamex, Paris, France
| | - Clairelyne Dupin
- Service de Pneumologie et Centre de Référence Constitutif des Maladies Pulmonaires Rares, Hôpital Bichat, Groupe Hospitalier Universitaire AP-HP Nord- Université de Paris, Paris, France
| | - Camille Taillé
- Service de Pneumologie et Centre de Référence Constitutif des Maladies Pulmonaires Rares, Hôpital Bichat, Groupe Hospitalier Universitaire AP-HP Nord- Université de Paris, Paris, France; INSERM UMR 1152, LabEx Inflamex, Paris, France.
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44
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Abstract
This review provides an evidence-based guide for the diagnosis, evaluation, and treatment of patients with asthma. It addresses typical questions that arise in the clinic-based care of patients with asthma and provides a basic and comprehensive resource for asthma care.
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45
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Fuhlbrigge AL. Correlation or Causation? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 6:114-115. [PMID: 29310756 DOI: 10.1016/j.jaip.2017.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 09/20/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Anne L Fuhlbrigge
- Department of Medicine, Pulmonary Sciences and Critical Care Division, University of Colorado School of Medicine, Aurora, Colo.
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46
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Chung LP, Hew M, Bardin P, McDonald VM, Upham JW. Managing patients with severe asthma in Australia: Current challenges with the existing models of care. Intern Med J 2019; 48:1536-1541. [PMID: 30517993 DOI: 10.1111/imj.14103] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/09/2018] [Accepted: 07/29/2018] [Indexed: 02/05/2023]
Abstract
Severe asthma leads to debilitating symptoms for patients and excessive socioeconomic burden for the community. Comprehensive models of care are required to address complex issues, risk factors and comorbidities in patients with severe asthma, and to identify patients most appropriate for specialised treatments. Dedicated severe asthma services improve asthma control, reduce asthma exacerbations and hospital admissions, and improve quality of life. Currently, diverse models of care exist for managing severe asthma across Australia. Most referrals to severe asthma services are from respiratory physicians seeking a second opinion or from primary care for poorly controlled asthma. Despite benefits of specialised severe asthma services, many patients are not referred and resources are limited, often resulting in long waiting times. Patient referral is often unstructured and there are considerable variations in the management of severe asthma with limited access to other health care professionals such as speech pathologists and dieticians, and restricted scope to optimise patient work-up before referral. Ongoing communication between the specialist and referring clinician is essential for continuity of care but is often lacking. Referral pathways can be optimised by developing referral criteria and guidelines to triage patients with severe asthma and to improve resource efficiency. Additional education and tools for assessing and managing severe asthma are needed, and mechanisms should be developed for involving primary care in the management of stabilised patients. Strategies to increase patient access to multidisciplinary services are recommended.
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Affiliation(s)
- Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Mark Hew
- Department of Allergy, Asthma and Clinical Immunology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Philip Bardin
- Monash Medical Centre, Monash University, Melbourne, Victoria, Australia
| | - Vanessa M McDonald
- Centre of Excellence in Severe Asthma and Centre for Healthy Lungs, The University of Newcastle, Newcastle, New South Wales, Australia
| | - John W Upham
- Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia
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47
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Chung LP, Johnson P, Summers Q. Models of care for severe asthma: the role of primary care. Med J Aust 2019; 209:S34-S40. [PMID: 30453871 DOI: 10.5694/mja18.00119] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/28/2018] [Indexed: 01/18/2023]
Abstract
Severe asthma encompasses treatment-refractory asthma and difficult-to-treat asthma. There are a number of barriers in primary, secondary and tertiary settings which compromise optimal care for severe asthma in Australia. Guidelines recommend a multidimensional assessment of severe asthma, which includes confirming the diagnosis, severity and phenotype and identifying and treating comorbidities and risk factors. This approach has been found to improve severe asthma symptoms and quality of life and reduce exacerbations. Primary care providers can contribute significantly to the multidimensional approach for severe asthma by performing spirometry, optimising therapy and addressing risk factors such as non-adherence and smoking before referring the patient to a respiratory physician for review. Primary care practitioners are encouraged to remain engaged with the management of a patient with severe asthma following specialist review by assisting with community-based allied health referrals, managing general medical comorbidities and administering prescribed biological therapies. Specialists can support primary care by providing advice to individuals with indeterminate diagnosis, streamlining investigation and management of unrecognised risk factors and complex comorbidities, optimising treatment for severe or difficult asthma including assessment of suitability for and, if appropriate, initiating advanced therapies such as biological therapies. When discharging patients back to primary care, specialists should provide clear recommendations regarding ongoing management and should specify the indications requiring further specialist review, ideally offering a streamlined re-referral pathway.
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48
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Azim A, Mistry H, Freeman A, Barber C, Newell C, Gove K, Thirlwall Y, Harvey M, Bentley K, Knight D, Long K, Mitchell F, Cheng Y, Varkonyi-Sepp J, Grabau W, Dennison P, Haitchi HM, Arshad SH, Djukanovic R, Wilkinson T, Howarth P, Kurukulaaratchy RJ. Protocol for the Wessex AsThma CoHort of difficult asthma (WATCH): a pragmatic real-life longitudinal study of difficult asthma in the clinic. BMC Pulm Med 2019; 19:99. [PMID: 31126281 PMCID: PMC6534885 DOI: 10.1186/s12890-019-0862-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 05/15/2019] [Indexed: 01/19/2023] Open
Abstract
Background Asthma is now widely recognised to be a heterogeneous disease. The last two decades have seen the identification of a number of biological targets and development of various novel therapies. Despite this, asthma still represents a significant health and economic burden worldwide. Why some individuals should continue to suffer remains unclear. Methods The Wessex Asthma Cohort of Difficult Asthma (WATCH) is an ongoing ‘real-life’, prospective study of patients in the University Hospital Southampton Foundation Trust (UHSFT) Difficult Asthma service. Research data capture is aligned with the extensive clinical characterisation required of a commissioned National Health Service (NHS) Specialist Centre for Severe Asthma. Data acquisition includes detailed clinical, health and disease-related questionnaires, anthropometry, allergy and lung function testing, radiological imaging (in a small subset) and collection of biological samples (blood, urine and sputum). Prospective data are captured in parallel to clinical follow up appointments, with data entered into a bespoke database. Discussion The pragmatic ongoing nature of the WATCH study allows comprehensive assessment of the real world clinical spectrum seen in a Specialist Asthma Centre and allows a longitudinal perspective of deeply phenotyped patients. It is anticipated that the WATCH cohort would act as a vehicle for potential collaborative asthma studies and will build upon our understanding of mechanisms underlying difficult asthma. Electronic supplementary material The online version of this article (10.1186/s12890-019-0862-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adnan Azim
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Heena Mistry
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK
| | - Anna Freeman
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Clair Barber
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Colin Newell
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kerry Gove
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Yvette Thirlwall
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Matt Harvey
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kimberley Bentley
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Deborah Knight
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Karen Long
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Frances Mitchell
- The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK
| | - Yueqing Cheng
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Judit Varkonyi-Sepp
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Paddy Dennison
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Hans Michael Haitchi
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Institute for Life Sciences, University of Southampton, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - S Hasan Arshad
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Institute for Life Sciences, University of Southampton, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK
| | - Ratko Djukanovic
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Institute for Life Sciences, University of Southampton, Southampton, UK
| | - Tom Wilkinson
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Institute for Life Sciences, University of Southampton, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Peter Howarth
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Institute for Life Sciences, University of Southampton, Southampton, UK.,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ramesh J Kurukulaaratchy
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK. .,National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK. .,Asthma Allergy and Clinical Immunology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK. .,The David Hide Asthma & Allergy Research Centre, St Mary's Hospital, Newport, Isle of Wight, UK. .,Respiratory Medicine & Allergy, Asthma, Allergy & Clinical Immunology, Mailpoint 52, Floor 2 Minerva House, Southampton General Hospital, Tremona Road, Southampton, Hampshire, SO16 6YD, UK.
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49
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Hull JH. Multidisciplinary team working for vocal cord dysfunction: Now it's GO time. Respirology 2019; 24:714-715. [PMID: 30977222 DOI: 10.1111/resp.13560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 03/26/2019] [Indexed: 12/13/2022]
Affiliation(s)
- James H Hull
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK
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50
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Severe Asthma Global Evaluation (SAGE): An Electronic Platform for Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1440-1449. [PMID: 30954467 DOI: 10.1016/j.jaip.2019.02.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/22/2019] [Accepted: 02/27/2019] [Indexed: 01/26/2023]
Abstract
Severe asthma is complex and heterogeneous; ad hoc outpatient assessment can be suboptimal. Systematic evaluation improves outcomes and is recommended by international guidelines. Electronic templates improve physician performance and clinical processes, and may be useful in severe asthma systematic evaluation. We developed the Severe Asthma Global Evaluation (SAGE) electronic platform to streamline this process, via Research Electronic Data Capture (REDCap). It incorporates: a questionnaire battery for patient completion before clinical consultation; asthma and comorbidity modules; a clinical summary page in an asthma management module; a nurse educator module; a structured panel discussion record; and an automatically generated report incorporating all key data. SAGE incorporates 282 clinician input fields, with a typical consultation requiring completion of 169. To streamline the process SAGE contains 34 autocalculations and 20 decision support tools. It incorporates all 95 core variables of the International Severe Asthma Registry, with which it is directly compatible. SAGE improves symptom control and exacerbations in patients with difficult asthma. In conclusion, we developed and validated an electronic platform that facilitates a comprehensive but streamlined systematic evaluation of severe asthma that is available for free download via REDCap. Its use enhances management of patients with severe asthma and facilitates audit and international research collaboration.
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